THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 


M  Y  O  M  A  T  A 


OF  THE 


UTERUS 


HOWARD    A.    KELLY  and        THOMAS    S.    CULLEN 

PROFESSOR    OF    (Gynecology  in  the   johns  associate  professor  of  gynecology,  johns 

HOPKINS     university;      GYNECOLOGIST-IN-  HOPKINS   UNIVERSITY;     ASSOCIATE  CYNKCOLO- 

CHIEF     TO      THE      JOHNS      HOPKINS      HOSPITAL  GIST       TO       THE      JOHNS       HOPKINS       HOSPITAL 


I  LLU S r RATE D 

AUGUST    HORX    mid   HERMAXX    HF.CKER 


l'Illl.AI)i:i,rHIA    AM)    LONDON 

W.   B.  SAUNDERS   COMPANY 

1909 


Copyright,  1909,  by  W.  B.  Saunders  Company 


PRINTED    IN    AMERICA 


/  / 


%J^ 


TO  THE  MEMORY  OF 

Xeselic  flDattbew  Swectnam 

OF  THE   UNIVERSITY  OF   TORONTO. 

A   MAN   OF   RARE   SURGICAL    JUDGMENT    AND    A    TRUE    FRIEND 


PREFACE 

Ix  1S94  we  commenced  a  careful  study  of  uterine  myomata  and  contemplated 
publishing  the  results  of  our  findings.  A  year  later,  however,  the  work  was  tem- 
porarily laid  aside,  as  it  was  deemed  wiser  to  take  up  the  subject  of  carcinoma  of 
the  uterus.  After  the  publication  of  that  work  in  1900  we  again  turned  our  atten- 
tion to  uterine  myomata,  and  since  that  time  we  have  been  contuiually  gathering 
data  on  that  subject. 

Our  material  has  been  drawn  from  (1)  the  cases  operated  upon  at  the  Johns 
Hopkins  Hospital  from  the  opening  of  the  institution  in  1889  to  January  1, 
1909;  (2)  those  that  have  come  under  the  care  of  Dr.  Kelly  at  his  private  hospi- 
tal; and  (3)  those  operated  upon  by  me  at  the  Church  Home  and  Infirmary,  at 
the  Caml^ridge  (Maryland)  Hospital,  and  at  the  Emergency  Hospital  in  Fred- 
erick. The  total  number  of  cases  examined  was  1674.  After  obtaining  complete 
abstracts  of  the  histories,  the  tumors  were  again  examined,  and  many  new  and 
interesting  changes  were  found  that  had  been  overlooked  in  the  regular  routine 
lal)oratory  examinations.  Descri})tions  of  the  gross  and  histological  appearances 
of  the  myomata  were  made,  and  these  descriptions  were  then  attached  to  their 
respective  histories. 

After  carefully  surveying  the  great  wealth  of  material,  the  question  arose  as 
to  the  advisability  of  reviewing  the  vast  amount  of  current  literature  on  myo- 
mata, and  it  was  found  that  to  adeciuately  cover  it,  and  at  the  same  time  fully 
discuss  our  own  material,  would  necessitate  the  ])ul)lication  of  three  or  more 
volumes.  Under  these  circumstances,  we  felt  that  no  one  would  wish  to  read  so 
much  on  one  subject,  and  that  it  would  be  wiser  to  confine  our  effoiis  to  a  thor- 
ough study  of  our  own  material,  with  which  we  were  thoroughly  familiar.  The 
present  volum(\  therefore,  deals  almost  exclusively  with  the  work  clone  l)y  those 
connected  with  the  gynecological  department  of  the  Johns  Hopkins  Hospital  and 
of  the  Johns  Ilojjkins  I'niversity. 

it  nia\'  b(-  of  interest  briefly  to  detail  the  method  ado]ite(|  in  coi-relat ing  tiie 
many  j)oints  of  interest  contained  in  the  large  amount  of  material.  WC  starteil 
off  without  any  i)reconceived  theories  and  determined  to  cai'efully  analyze  the 
cases  at  our  disposal.  After  several  months  of  indecision  as  to  the  best  method 
of  handling  the  subject,  we  finally  adojjfed  the  card  system.  l''.\-ery  history  and 
))ath()l()gical  desci'ii)tion  was  I'ead  and  each  point  of  importance  was  underscored. 
Then  a  card  was  made  of  each  point.  This  card  also  had  the  case  number  and 
the  jiatliological  nunibei-.     Some  cases  contained  little  or  nothing  of  interest; 

V 


VI  phi:  FACE. 

for  other  casos,  from  live  to  ten  cards  were  necessary.  As  a  result  we  had  several 
thousand  cards.  These  naturally  fell  under  certain  main  headings.  This  gave 
us  a  more  concrete  idea  of  the  material  and  clearly  hidicated  the  chapter  classi- 
fication. The  card-index  was  of  the  greatest  assistance;  in  the  first  place,  be- 
cause it  enahled  us  to  get  every  jwint  of  interest,  and,  secondly,  because  when 
a  given  subject  was  undcM'  discussion  it  was  only  necessary  to  pick  out  the  cards 
of  that  grou|)  and  then  select  the  ten  or  twenty  histories,  as  the  case  might  be, 
instead  of  each  time  going  through  sixteen  huiidi'ed  histoi'ies,  with  a  strong  like- 
lihood of  overlooking  several  cases.  We  fully  realize  the  im]X)rtant  part  played 
by  the  many  assistant  residents  and  the  residents  of  the  Gynecological  Depart- 
ment shice  the  opening  of  the  Hospital;  had  it  not  been  for  their  careful  and  con- 
scientious histories  and  descriptions  of  the  various  operations  jjcrformed,  this 
work  would  have  been  impossible. 

On  account  of  the  great  im))ortance  of  sarcomatous  changes  occui'ring  in  or 
associated  with  myomata  and  the  by  no  means  infrequent  association  of  carci- 
noma of  the  fundus  with  myomata,  we  have  considered  both  of  these  subjects 
at  unusual  length. 

The  chapter  on  adenomyoma  I'eached  such  large  projiortions  that  we  found  it 
necessary  to  deal  with  the  subject  in  a  separate  volume.*  On  the  other  hand,  the 
chapter  on  myoma  and  jjregnancy  is  rather  fi'agmentary,  as  we  do  no  obstetrical 
work. 

We  ha\"e  not  discussed  the  histoiy  of  tlie  development  of  the  surgical  proced- 
ures appropriate  to  uterine  myomata.  This  has  been  so  well  handled  by  Dr. 
Charles  P.  Noblef  that  nothing  would  be  gained  by  duplicating  the  account. 
( )nly  the  various  operative  procedures  that  we  personally  have  used  are  described. 
Dr.  Kelly  being  out  of  the  cit}',  it  devolved  upon  me  to  briefly  outline  the  scope 
of  the  book,  and  altliough  1  know  he  would  be  averse  to  any  personal  mention  of 
his  work,  I  feel  it  my  duty  to  say  a  few  words  relative  to  his  share  in  the  develop- 
ment of  oi)erations  for  myomata.  It  was  iii}-  good  fortune  to  come  to  Haltimore 
in  1891,  shortly  after  the  hospital  opened.  At  that  time  many  cases  of  nu'oma 
were  considered  inoperable,  and  even  when  hysterectonn-  was  undertaken  it 
was  only  in  the  cases  in  which  a  stout  rubber  ligature  could  be  temporarily  tied 
around  the  cervix:  and  when,  as  happened  in  some  cases,  this  ligature  slipped, 
alarming  liemorrhage  follow(Ml.  Then  came  the  systematic  controlhng  of 
each  of  the  cardinal  vessels;  latei'  the  bisection,  and  finally  the  transverse  sever- 
ance of  the  cervix  as  a  pi'eliminary  feature  of  the  opei'ation  in  exceptionally  diffi- 
cult cases,  until  at  ])resent  a  myomatous  uterus  that  cannot  be  removed  is  al- 
most unheard  of.  1  have  watched  the  gradual  simplifications  of  the  surgical 
procedures  with  the  greatest  interest.  Many  American  surgeons  have  had  much 
to  do  with  the  wonderful  adxance  in  this  direction,  but  I  know  of  no  other  man, 

*T!ionui.s  S.  Cullen,  Adenomyoma  of  the  Uterus,  W.  B.  Saviiidors  Co.,  190S. 
fin    Krlly-Xoble,   (lynecology  and   .\bdoniinal    Surgery,   vol.   i.  p.    660.   W.    B.   Saunders 
Co..  HM)S. 


PREFACE.  Vll 

either  here  or  abroad,  who  lias  done  as  much  toward  this  advancement  as  Howard 
A.  Kehv. 

AVe  have  purposely  laid  much  stress  on  the  mistakes  and  mishaps  that  have 
occurred,  and  have  given  our  deaths  in  full,  as  we  feel  that  much  more  can  often 
be  learned  from  failures  than  from  successes.  Moreover,  we  felt  that  a  frank 
statement  of  our  mishaps  might  help  other  surgeons  to  aA'oid  the  un])leasant 
complications  that  we  have  occasionally  encountered. 

Our  mortality,  taking  all  the  cases  from  1889  to  July  1,  190G,  was  rather 
high — between  5  and  6  per  cent.  It  included  all  the  early  cases,  but  also  embraced 
many  of  the  desperate  cases  and  also  many  cases  of  myoma  associated  with  ma- 
lignancy.   Just  before  going  to  press  we  have  gone  over  the  histories  from  July 

I,  1906,  to  January  1,  1909,  and  find  that  in  238  myoma  operations  the  death- 
rate  has  been  less  than  1  per  cent. — an  evidence  of  a  continued  improvement  in 
our  operative  technique. 

The  work  would  not  have  been  complete  without  some  reference  to  the  au- 
topsy findings  m  a  large  number  of  cases.  Professor  William  H.  Welch  kindly 
placed  his  valuable  records  at  our  disposal.  We  are  also  deeply  mdebted  to 
him  for  the  sympathetic  co-operation  he  has  always  accorded  us  in  the  labora- 
tory studies. 

To  the  casual  observer  the  preservation  of  myomatous  material  to  the  extent 
of  several  tons  would  seem  unnecessary,  but  Dr.  Henry  M.  Hurd  has  assisted  us 
in  every  way.  This  foresight  has  been  of  the  greatest  value  in  many  instances, 
notably  in  those  cases  in  which  sarcoma  had  been  overlooked  at  the  first  examina- 
tion, or  in  which  subsecjuently  to  a  supposedly  simple  hysteromj'omectomy,  a 
sarcoma  developed  in  the  stump.   We  also  owe  much  to  Dr.  Hurd  for  his  advice. 

The  illustrations  have  been  made  with  wonderful  accuracy  in  detail  l)y  Mr. 
August  Horn  and  Mr.  Hermann  Becker.  Further  comment  is  unnecessary,  as 
the  pictures  speak  for  themselves.  We  are  also  fortunate  in  having  several  exam- 
ples of  Mr.  Max  Brodel's  w^ork.  "\Vhen  it  is  said  that  a  drawing  has  been  reduced 
one-half,  linear  measurement  is  intended.  In  rcalit}-  llic  flat  surface  of  the 
l)icture  is  only  one-fourth  the  natural  size.  It  is  well  to  beai-  lliis  ])()iiit  in  mind, 
otherwise  the  reader  will  not  get  an  adequate  concej)ti()n  of  the  aclual  size. 
With  few  exceptions  the  ilhislrations  are  original.     \\c  wisli  to  thank  Dr.  (ieorge 

II.  Simmons  for  allowing  us  to  use  several  of  the  illustrations  which  we  have  al- 
ready })ublished  in  the  "Journal  of  the  American  Medical  Association."' 

To  .Mr.  Harry  Hall  and  Mr.  Hardy,  of  the  Surgeon-GeneraTs  Library,  we  ai-e 
indebted  for  tlicii-  kind  assistance  rendered  while  we  wvvr  Nciifying  llie  literature. 

Dr.  Herbert  I.  Cole,  of  Mobile,  Ala.,  rendered  much  assistance  in  the  ])rei)ai-a- 
tion  of  the  cha])tcr  dealing  with  tlie  findings  at  autopsy. 

.Ml'.  P)eiijaiiiin  0.  McCleai'V  made  most  of  the  slides  from  which  the  histolog- 
ical pictures  ha\e  l)een  dfawn.  lie  also  i-eiidered  most  \alual)le  aid  in  con- 
trolling the  man}'  nuiulx-i's  scattere*!  throughout  the  book  and  also  in  checking 
off  all  measurements. 


VIU  PKKFACE. 

Our  thanks  are  due  Dr.  l'"raiik  H.  Smith,  not  only  fof  his  correction  of  the 
proof-sheets,  but  also  for  his  kind  ciiticisni  of  their  contents.  In  numerous 
phices  he  has  indicatetl  that  the  original  text,  while  satisfactory  to  the  specialist, 
miiiht  not  have  conveyed  the  proj)er  meanino;  to  the  general  practitioner. 

Dr.  lamest  K.  ("ulleii  spent  his  entire  time  for  over  a  year  in  locating  former 
jiatients,  in  lilling  in  mi.ssing  data,  and  in  analyzing  the  cases  from  numerous 
standpoints,  lie  has  also  devoted  much  time  to  the  book  in  the  last  two  years, 
and  during  the  progress  of  the  work  has  made  many  valuable  suggestions.  He 
has  carefully  followed  the  proof-sheets  through  the  press,  paying  especial  attention 
to  the  accuracy  of  the  numbers.  It  is  imj)ossible  for  us  to  adequately  thank  him 
foi'  the  large  shai'c  lie  has  had  in  the  making  of  this  volume. 

Miss  ("ora  Iveik  has  l)een  of  the  greatest  assistance  to  us  in  the  gathering  of 
the  histories  and  lal)oratory  abstracts  and  in  the  pre))arati()n  of  the  manuscript. 

( )ur  thanks  are  also  due  to  the  W.  B.  Saunders  Company,  who  have  done  all 
ill  their  power  to  procure  the  best  possible  i-epioductions  of  the  illustrations  and 
to  facilitate  the  progress  of  the  book  through  the  press. 

In  conclusion  we  can  only  say  that  if  the  reader  gets  a  tithe  of  the  j)leasure 
from  the  pcn'usal  of  this  volume  that  we  did  in  gathering  the  material  its  function 
will  ha\'e  been  fulfilled. 

Thom.\s  S.  Cullex. 

B.«LTIM()E<E,    Ml).. 

•lune.  1909. 


CONTENTS 

Chaptkr  Pa(;e 

I.  Uterine  Myomata 1 

II.  Parasitic  Uterine  Myomata 13 

III.  Cervical  Myomata ')3 

IV.  Submucous  Myomata ')9 

V.  Dilatation  of  the  Uterine  Lymphatics  Associated  with  Myomata 72 

VI.  Torsion  of  the  Uterus 77 

VII.  Hyaline  and  Cystic  Degeneration S3 

VIII.  Calcification  of  Uterine  Myomata 12G 

IX.  Suppurating  Uterine  Myomata 134 

X.  Myomata  Associated  with  Malformations  of  the  Uterus 155 

XI.  Angiomy'Oma 158 

XII.    LiPOMYOMA  OF  THE  UtERUS 162 

XIII.  Adenomyoma  of  the  Uterus 167 

XIV.  Myosarcoma  of  the  Uterus 169 

XV.  Carcinoma  of  the  Cervix  Associated  with  Uterine  Myomata 262 

XVI.  Adenocarcinoma  of  the   Body  of  the  Uterus  Associ.^ted  with   Uterine 

Myomata 274 

XVII.  The  Condition  of  the  Uterine  Mucosa  in  Cases  of  Myoma 297 

XVIII.  Conditions  of  the  Tubes  and  Ovaries  when  Uterine  Myomata  are  Present  . .  337 

XIX.  Conditions  Found  in  the  Ligaments  Passing  to  and  from  the  Uterus  in 

Cases  of  Uterine  Myomata 354 

XX.  The  Bladder  in  Cases  of  Uterine  Myomat.\ 365 

XXI.  The  Ureters  in  Cases  of  Uterine  Myomata 378 

XXII.  The  Rectal  Findings  in  Cases  of  Uterine  Myomata 3S6 

XXIII.  Analysis  of  the  Cases  of  Uterine  Myomata  Found  at  Aittopsy  ln  the  Patho- 

logical Laboratory  of  the  Johns  Hopkins  Hospital  from  the  Opening  of 

the  Hospital  in  1889  to  July  1,  1906 394 

XXIV.  The  Cause  of  Uterine  Myomata 430 

XXV.  The  Symptoms  Associated  with  Uterine  Myomata 434 

XXVI.  Other  Pathologic  Conditions  in  Some  of  our  Myoma  Cases 460 

XXVII.  Differential  Diagnosis 467 

XXVIII.   The  Effect  of  Removal  of  the  Ovaries  on  I'terine  Myomata 504 

XXIX.  Abdominal  Myomectomy 506 

XXX.  Vaginal  Myomectomy 571 

XXXI.  Abdominal  Hysteromyomectomy 5SS 

XXXII.  Difficult  Abdominal  Hystehectomies (130 

XXXIII.  PrEG.VANCV   AM)    ri'KHINF.    MvoM  AlA 613 

XXXIV.  Complications  Following  Ahdominal  Hysteromyomectomy 654 

XXXV.  Results  of  Operations  for  I^terine  Myomata 671 


Index  oi'  Casks  .Arranged  Accordim;  to  '1'hkik  (  Ivn'Ecologicai,  N'imhkrs.  .  .  .  689 

Patiiologicai,  Xumheus 697 

.Ai  ■I'oi's'i    .NiMHioiis 701 

]ni)i:\ 703 


LIST  OF  ILLUSTRATIONS 

Fig.  Page 

1.  Sessile  and  Pedunculated  Myomata   2 

2.  Mulberry-shaped  and  Sessile  Myxoma 2 

3.  An  Ordinary  Myomatous  Uterus  on  Section 3 

4.  A  General  "My'omatous  Tendency" 4 

5.  Injection  of  a  My'omatous  Uterus 6 

6.  Typical  Myxomatous  Tissue 7 

7.  The  Line  of  Cleavage  Between  a  Myoma  and  the  Uterine  Muscle 8 

8.  Blending  of  a  Myoma  with  the  Uterine  Muscle 9 

9.  The  Irregular  Extension  of  a  Myoima  into  the  Uterine  Muscle 10 

10.  A  Transverse  Section  Through  a  Myomatous  Uterus 11 

11.  The  Myxomatous  Uterus  as  Viewed  on  Transverse  Section  Through  the  Cervix  ...      11 

12.  Omental  Blood-vessels  that  are  Keeping  Alive  the  Outer  Layers  of  a  Myoma 

which  Shows  Almost  Total  Hyaline  Degeneration 15 

13.  A  Partially  Parasitic  My'oma  Receiving  Most  of  its  Blood-supply-  fro.m  the 

Omentum 17 

14.  A  Partially    Parasitic    My'oma    Receiving    a    Large     Blood-supply'  from    the 

Omentum 17 

15.  A  Large  Pedunculated  My'oma  Receiving  Nearly  all  of  its  Blood-supply  from 

THE  Omentum 18 

16.  A  Very'  Large  Subperitoneal  and  Pedunculated  Myoma,  Receiving  Most  of  its 

Nourishment  from  the  Omentum 19 

17.  A  Very  Large  Pedunculated  and  Partially  Necrotic  Myxoma  Receiving  a  Rich 

Blood-supply'  from  the  Omentum 20 

18.  A  Parasitic  Myoma  Receiving  a  Large  Blood-supply'  from  the  Omentum.     Partial 

Atrophy  of  the^Omental  Fat 22 

19.  Marked  Disappearance  of  the  Fat  in  an  Adherent  Omentum 23 

20.  The  Gradual  Disappearance  of  Omental  Fat  when  the  Omentum  sends  many 

Vessels  to  a  Parasitic  Myoma 25 

21.  A  Large  Parasitic  Myoma  with  Huge  Vessels  Coming  from  the  Omentum 26 

22.  Large  Congeries  of  Omental  Vessels  Supplying  Nourishment  to  a  Myomatous 

Uterus;  also  Vessels  Passing  up  from  the  Bladder  to  the  Tumor 28 

23.  A  Large  Myoma  Entirely  Separated  from  the  Uterus  and  Lying  Free  ix  the 

Omentu.m 29 

24.  Omental  Vessels  Supplying  a  Subperitoneal  Peduncul.vted  Myoma,  and  Asso- 

ciated with  7000  CO.  of  Ascitic  Fluid 34 

25.  A  Partially-  Parasitic  Uterine  Myoma  Associated  with  51  Liters   of  Ascitic 

Fluid 36 

26.  A  Partially  P.yrasitic  Myo.ma  Receiving  P.vrt  of  its  Nourishment  from  the 

Fallopian  Tubes 37 

27.  A  Parasitic  Myoma  i.v  no  Way  Connected  with  the  Uterus 39 

28.  MULTI.NODULAR  MYOMATOUS  UtERUS  WITH  A    LkFT  Pus-TI'HE 40 

29.  A  Myo.ma  Receiving  .much  of  its  NornisiiMi:\i'  fuom  iiii;  Ukcitm  and  .Vpi'vukntlv 

FRO.M  THE  Right  Ovary  and  Tube 42 

.30.  A  Large  Subperitoneal  Pedunculated  My'oma,  Receiving  much  of  its  Noruisii- 

me.nt  from  the  Intp:stines 43 

31 .  A  Spleen-shaped  Myoma 45 

32.  A  Suppurating  Subpkhitonf.al  Myom.v  Co.m.munhating  with  thf,  Tyumen  of  thk 

Cecum 46 


XU  LIST    OF    ILLT'STUATIOXS. 

Fig.  '  Page 

33.  A  Myoma  Rkceivixg  its  Xoukishmext  fuo.m  the  Mesexteky  ok  the  Small  ]5owel 

VXD    COXTAIXIXG    AX    AbSCESS   C.VVITY    WHICH    Co.NLMl.MCATEU    WITH    THE    LlMEX    OF 

THE  IXTESTIXE 47 

34.  Peduxcul.vted  Myomata  Receivixg  a  Lauge  Part  of  theik  N'ormsHMEXT  kkom  the 

Bladdeh oO 

3.).  A  .MiLriNoDiL  \K  .Myomatous  Uterus  with  Vessels  Passixg  fkom   ihk,  HiciHT  An- 

Du.MiXAL  Wall  axu  Appendix  to  a  Large  Pedunculated  Myo.\lv 52 

3().  Myoma  of  the  Broad  Lig.\ment  and  Cervix 53 

37.  A  Myoma  of  the  Broad  Ligament  and  Cervix 54 

38.  A  Cervical  Myoma 55 

39.  Cervical  Developmext  of  Myomata 56 

40.  A  Very  Large  Cervical  My'oma 57 

4L  E.\TEXsivE  Cervical  Developmext  of  a  Myoma 58 

42.  A  SuBMi'cous  Myoma  Fillixg  the  TTterine  C.wity 59 

43.  -Marked  Suh.mucous  Development  of  Uterine  Myomata 60 

44.  Extensive  Sub.mucous  Development  of  Uterine  Myomata 60 

45.  A  Large  Pedunculated  Submucous  MyoiMA 61 

46.  A  L.\.rge  Pedunculated  Sub.mucous  Myoma 62 

47.  A  Portion  of  a  Large  I.nterstitial  Myoma  i  hat  has  Become  Submucous  and  Shows 

Early  Signs  of  Breaking  Down 63 

48.  A  Large  Pedunculated  Submucous  Myoma 64 

49.  A  Lobul.\ted  Submucous  Myoma  Pro.iecting  Through  the  Cervix 64 

50.  A  (Iaxgrexous  Sub.mucous  Myoma 64 

51 .  A  Sloughixg  Submucous  Myoma 65 

52.  A  Very  L.vrge  Submucous  Myoma  which  had  been  Extruded  from  the  Uterus 66 

53.  A  Sloughing  Submucous  Myoma 67 

54.  The  Surface  of  a  Sloughing  Sub.mucous  Myoma 68 

55.  The  Superficial  Portions  of  a  Sloughing  Submucous  Myoma 69 

56.  The  Surface  of  a  Sloughing  Submucous  Myoma 69 

57.  E.voR.MOus  DiLAT.vno.N  OF  the  Lymphatics  on  the  Sitrface  of  a  Myomatous  Uterus.  73 

58.  DiL.vTED  Ly.mph.\tic  Sp.\ces  i.v  the  Uterine  Wall  in  the  Neighborhood  of  the 

Right  Tube  a.\d  Ovary 74 

59.  DiL.\TED  Lymph.\tic  Ch.\nnels  .\t  the  Left  T'tk:ri.\e  Hor.x    hetweex   the   Tube 

and  Ovary  and  between  the  Tube  and  Left  Round  Ligament 75 

60.  Rot.vtion  of  a  Myom.\tous  Uterus  on  its  Cervix 77 

61    Atrophy  of  the  Cervix  Associated  with  a  Large  CJlobular  Myomatous  Uterus  ...  78 

62.  Marked  Torsion  of  a  Myomatous  Uterus 78 

63.  Torsion  of  .v  L.\rge  Globular  My'om.\tous  Uterus 79 

64.  Spont.\neous  Amput.\tio.\  of  a  Myo.m.\tous  Uterits 80 

65.  Torsion  of  a  Subperitoneal  Pedunculated  Myo.ma 81 

66.  Sudden  Torsion  of  a  SuBPERrroNE.\L  Pedunculated  .Myo.ma  with  Complete  Shut- 

ting OFF  OF  its  Blood-supply 82 

67.  Abrupt  Tr.vnsformation  of  Myom.\tous  into  Hyaline  Ti.ssue 84 

68.  Focal  Hyaline  Degeneration  in  Muscle-bundles 85 

69.  M.\rked  Hyaline  Degeneratio.x  of  the  W.\lls  of  the  Blood-Vessels  in  a  Myo.ma.  .  86 

70.  Hyaline  Degeneration  in  the  Ckntek  of  .vn  iNTEusirriAL  .Myoma 87 

71 .  Edema  ok  a  Myo.m.\ 88 

72.  Hyaline  Degeneratio.x  with  Cystic  For.matiox  in  a  Small  Subperitoneal  Pedun- 

culated Myo.m.y 89 

73.  Extensive  and  Sharply   Dekinkd   Hyaline   Degkxer.\tiox   ix   a  Subperitoneal 

Myoma 93 

74.  Marked  Hyaline  Degeneration  with  Liquef.vctiox  ix  .\x  I.nterstitial  .Myoma  ....  95 

75.  Cystic  Degeneration  oka  Portion  of  a  Peduncul.vted  Subperitoneal  .Myoma  ....  96 

76.  Cystic  Degevkk  xttov  i\  \  I,  \rge  Subperitoneal  Pedunculated  Myoma 98 


LIST    OF    ILLUSTRATIOXS.  XI 11 

Fig.  Page 

77.  Marked  Proliferation  of  the  Endothelium  of  the  Capillaries   Dividing  the 

Myomatous  Tissue  into  Alveoli 99 

78.  Coagulation  Necrosis  and  Hyaline  Degeneration  in  an  Interstitial  Myoma 100 

79.  General  and  Diffuse  Cystic  Formation  in  a  Myoma 101 

80.  The  General  Contour  and  Relations  of  the  Myoma  seen  in  Fig.  81 102 

81.  Complete  Cystic  Degeneration  of  Portions  of  a  Myoma  that  had  Undergone 

Hyaline  Degeneration 102-103 

82.  Gradual  Liquefaction  of  a  Myoma 103 

83.  Liquefied  and  Hyaline  Areas  in  a  Myoma 104 

84.  Liquefaction  and  Hyaline  Areas  in  a  Myoma 106 

85.  Hyaline  Degeneration  with  Liquefaction  of  an  Interstitial  Uterine  Myoma  ....  107 

86.  Massive  Hyaline  Degener.\tion  and  Liquefaction  of  a  Large  Uterine  Myoma  ....  109 

87.  A  Cystic  Subperitoneal  Pedunculated  Myoma 110 

88.  A  Multilocular  Cystic  Myo.ma Ill 

89.  A  Large  Cystic  Myoma  Growing  fro.m  the  Posterior  Sttrface  of  the  Uterus 113 

90.  A  Large  Subperitoneal  Cystic  Myo.ma .• 114 

91 .  A  Cystic  Myoma 115 

92.  A  Large  Multicystic  Myoma 117 

93.  A  Cystic  Myoma  Weighing  39  Pounds  and  Closely  Resembling  \  Multilocular 

Ovarian  Cyst 119 

94.  A  Cystic  Uterine  Myoma 120 

95.  A  Cystic  Myoma  Occupying  the  Anterior  Uterine  Wall 121 

96.  A  Cystic  Myoma  with  a  Cavity  Resembling  Somewhat  the  Interior  of  a  Heart.    122 

97.  Irregular  Cystic  Spaces  in  a  Myoma 123 

98.  A  Uterine  Myoma  with  Cystic  Sp.\ces  Containing  Material  Resembling  Melted 

Butter 124 

99.  A  Degener,\ted  Partly  Calcified  Myoma 126 

100.  Myomata  Representing  Various  Stages  of  Degeneration 127 

101.  Partial  Calcification  of  a  Myoma 128 

102.  Calcareous  Plates  in  the  Wall  of  an  Artery 129 

103.  A  Completely  Calcified  Subperitoneal  Myoma 131 

104.  A  Suppurating  Subperitoneal  Myoma 136 

105.  An  Intraligamentary  Suppurating  Myoma 138 

106.  A  Suppurating  Intralig.\.mentary  Myoma 139 

107.  A  Suppurating  Subperitoneal  Myoma 140 

108.  A  Suppurating  Subperitone.\l  Myoma 141 

109.  A  Suppurating  Myo.m.\  Opening  into  the  Colon 143 

1 10.  A  Suppurating  Interstitial  Myoma 145 

111.  Slight  Suppuration  of  an  Interstitial  Myoma  with  Perforation  into  the  Uter- 

ine Cavity 146 

112.  A  Suppurating  Interstitial  Myoma  Opening  into  the  Uterine  Cavity 14S 

113.  A    Large   Suppurating   Interstitial  Myoma   Opening   into  and   Infecting   the 

Peritoneal  Cavity  and  .vlso  Draining  into  the  Cavity  of  the  Uterus 151 

114.  A    Double    Uterus   Containing    Subperitoneal,    Interstitial,    .\nd    Sub.mucous 

.M  VOMATA 156 

1 1 5.  .\ngiomyoma 1 59 

116.  Multiple  Angio.myo.matois  i'cx  i  in  .\  .Mvo.ma l.")'.t  Hid 

117.  .\ngtomy()ma 160 

1  IS.  Lii'()\iv()\i A , 162 

1  I't.  l.iroNnoM A 163 

120.  l,ii'()MM)\i.\ 164 

121.  LlI'O.MVO.MA 11)5 

122.  .\  Sarcomatous  Nodii.k  i\  .\  I.argk  !'i:i,\  ic  lii.oon-VEssEi 175 

123.  Sarcomatous  Transform  \i  ion  of  a  SrnPF.RiToNKAi,  Myoma  with  Dknse  Adhesions 

TO  THE  ReCTU.M   AND    I'KI.VIC   \\  AM.S ISl 


XIV  LIST    OF   ILLUSTRATIONS. 

Fig.  Page 

124.  Transition'  of  Myo.matoi's  into  S.a.rco.\iatous  Tissue 182 

125.  Sarcomatous  Transformation  of  a  Myoma  with  a  SECoxnARY  Growth  on  the 

Posterior  Surface  of  the  Uterus 185 

V2{\.  My'osarcoma  of  the  Body  of  the  Uterus  with  a  Secondary  and  Pure  Sarcoma- 
tous Cockscomb-like  Growth  on  the  Posterior  Surface 186 

127.  The  Lobul.\ted  .\nd  Myom.\tous  Nodule  Removed  from  the  Left  Broad  Ligament 

IN  Fig.  125 187 

128.  COM.MENCING  SARCOMATOUS  Tr.\NSFOR.M.\TION  OF  MYOMATOUS  TiSSUE 188 

129.  A  Sarco.m.v  th.\t  has  Developed  from  an  Interstitial  My'oma 189 

130.  Sarcom.\  Developing  in  the  Cervical  Stump 191 

131.  Sarcomatous  Transformation  of  a  Uterine  Myoma.     Supravaginal  Amputation 

WITH  Return  of  the  Growth  in  the  Cervical  Stump 193 

132.  Sarcoma  of  the  Anterior  Uterine  Wall 197 

133.  A  Large  Sarcomatous  Nodule  Containing  an  Irregular,  Smooth-walled  Cavity' 

IN  ITS  Center 198 

134.  Probable  Sarcomatous  Transformation  of  Bundles  of  Myomatous  Tissue 199 

135.  Sarcoma  Developing  in  the  Center  of  a  Subperitoneal  My'oma 202 

136.  Sarcoma  Developing,  in  Part  at  least,  from  a  Submucous  Myoma 205 

137.  A  Myoma  Situ.vted  to  the  Right  of  the  Cervix  and  Showing  Early  Sarcomatous 

Changes 206 

138.  Sarcoma  Developing  in  the  Center  of  a  Large  Interstitial  Uterine  Myoma 209 

139.  Saucom.\  Developing  in  the  Interior  of  a  Myoma 211 

140.  Prob-A-ble  Sarcomatous  Transformation  of  a  Myoma;   also  Discrete  Myomatous 

AND  Sarcomatous  Nodules  in  the  Same  Uterus 213 

141.  Association  of  Myoma  and  Sarcoma  in  the  Same  Uterus 214 

142.  A   Sarcomatous   Uterus  Conforming  in  Contour   to   a   Globular   Myomatous 

Uterus 216 

143.  Sarcoma  and  Myoma  in  the  Same  Uterus 217 

144.  Mixed-celled  S.vrcoma  of  the  Uterus  Associated  with  Myomata  of  the  Uterus.  .  .    218 

145.  S.^.RCO.MA  OF  the  POSTERIOR  UtERINE  WaLL,  ORIGINATING  IN   A  My'OMA 220 

146.  Sarcomatous  Transformation  of  a  Multinodular  Pedunculated,  Subperitoneal 

Myoma 224 

147.  Suspicious  Cell  Changes  in  a  Myoma 225 

148.  Early  Sarcomatous  Changes  in  a  Myoma 225 

149.  Sarcomatous  Transformation  of  Myomatous  Tissue 226 

150.  Gradual  but  Direct  Transition  of  Myo.matous  into  Sarco.matous  Tissue 227 

151.  Sarcomatous  Transformation  of  Myom.vtous  Tissue 228 

152.  Sarcom.\tous  Transformation  of  Myom.\tous  Tis.sue 228 

153.  Sarco.matous  Transfor.mation  of  My'omatous  Tissue 228 

154.  S.\RCOMATOus  Transformation  of  Myomatous  Tissue 228 

155.  Junction  of  Myomatous  and  Sarcomatous  Tissue 229 

156.  A  Rapidly  Growing  Subperitoneal  Myoma  w^ith  Small  Papill.e-like  Outgrowths 

Springing  from  its  Surface 238 

157.  Diffuse  Myomatous  Thickening  of  the  Uterine  Wall.     Discrete  Submucous 

My'o.ma  and  a  SuBMUcoiTs  Myoma  Presenting  an  Appearance  Suggestive  of 
Sarco.m.v 241 

158.  Suggestion  of  Sarco.ma  in  a  S.mall  Sub.mucous  Myoma 242 

159.  Suspicious  Cell  Changes  in  a  Small  Submucous  Myoma 243 

160.  Suspicious  Cell  Changes  in  a  Sm.vll  Submucous  Myoma 243 

161.  Suspicious  Cell  Changes  in  a  Sm.vll  Submucous  Myoma 243 

162.  Large  Cells  Occurring  in  a  Simple  Interstitial  Myo.ma 248 

163.  Gl\nt-cells  in  an  Edematous  Myoma 250 

164.  Suspicious  Cell  Changes  in  an  Edematous  and  Partly  Subperitoneal  Myoma  ....    251 

165.  Giant-cells  from  an  Edem.\tous  Myoma 252 

166.  A  Large  Nucleus  in  a  Myoma 253 


LIST    OF    ILLUSTRATIONS.  XV 

Fig.  Page 

167.  Suspicious  Cell  Changes  in  a  Sloughing  Submucous  Myoma 253 

168.  Cell  Changes  in  a  Myoma  Undergoing  Partial  Coagulation  Necrosis 256 

169.  Squamous-celled  Carcinoma  of  the  Cervix;    Subperitoneal  and    Interstitial 

Myomata;  Double  Pyosalpinx;  Cyst  of  Left  Ovary 263 

170.  Squamous-celled  Carcinoma  of  the  Cervix  and  Submucous  Myoma  of  the  Body 

OF  THE  Uterus 265 

171.  Squamous-celled  Carcinoma  of  the  Cervix;    Partially  Calcified  Interstitial 

Myoma  in  the  Body  of  the  Uterus 268 

172.  Multiple  Small  Uterine  Myomata;  Primary  Carcinoma  of  the  Oa'ary;  Primary' 

Carcinoma  of  the  Uterus 272 

173.  Adenocarcinoma  of  the  Body  of  the  Uterus  Associated  with  Myomata 276 

174.  Carcinoma  of  the  Lower  Part  of  the  Body  and  Upper  Part  of  the  Cervix;  Uter- 

ine Myomata 277 

175.  Myoma  of  the  Cervix  and  Carcinoma  of  the  Body'  of  the  Uterus 278 

176.  Multiple  Uterine  Myomata;    Carcinoma  of  the  Lower  Part  of  the  Body  and 

Upper  Portion  of  the  Cervix 280 

177.  Multiple  Uterine  Myomata;  Carcinoma  of  the  Body  of  the  Utertts 282 

178.  Adenocarcinoma  of  the   Body   of  the   Uterus  Associated  with   Interstitial 

Myomata 283 

179.  A  Large  Myomatous  Uterus,  Showing  also  an  Adenocarcinoma  of  the  Body 285 

180.  Multiple  Uterine  Myomata;    Adenocarcinoma  of  the  Body  with  Extension  to 

the  Peritoneal  Surface 286 

181.  Myomata  and  Adenocarcinoma  of  the  Body  of  the  Uterus 288 

182.  A  Large  Myoma  of  the  Cervix;  Adenocarcinoma  of  the  Body  of  the  Uterus 290 

183.  Subperitoneal,   Interstitial  and   Submucous   Myomata;     Advanced   Adenocar- 

cinoma Involving  Cervix  and  Body 292 

184.  An  Adenocarcinoma  of  the  Body  of  the  Uterus,  so  Small  that  it  Could  not  be 

Recognized  Except  with  the  Aid  of  the  Microscope 295 

185.  Marked  Dilatation  of  the  Cervical  Glands,  with  a  Tendency  Toward  the 

Formation  of  a  Polyp 298 

186.  A  Cervical  Polyp 299 

187.  A  Cervical  Polyp 299 

188.  A  Rare  Form  of  Cervical  Polyp 300 

189.  A  Rare  Form  of  Cervical  Polyp 301 

190.  Suspicious  Epithelial  Changes  in  a  Gland  from  the  Cervix,  Associated  with  a 

Large  Myomatous  Uterus 303 

191    Suspicious  Epithelial  Changes  in  the  Mucosa  of  the  Cervix,  from  a  Large  Myo- 
matous Uterus 304 

192.  Suspicious  Proliferation  of  the  Cylindric  Surface  Epithelium  of  the  Cervix, 

Associated  with  a  Large  Myomatous  Uterus 305 

193.  A  Slit-like  Tortuous  Uterine  Cavity 3()<) 

194.  A  Very  Small  Uterine  Cavity  with  a  Large  Myoma  of  the  Fundus 307 

195.  Partial  Obliteration  of  the  Uterine  Cavity  with  Dis.\ppe.\r.\nce  of  the  Mucosa  .  3()S 

196.  Partial  Obliteration  of  the  Uterine  Cavity  Caused  by  a  Submucous  Myoma 309 

197.  A  Large  Clot  in  the  Uterine  Cavity 310 

198.  Thickening  of  the  Uterine  Mucosa 311 

199.  Thickening  of  the  Mucosa  in  a  Myomatous  Uterus 312 

200.  Moderate  Thinning-out  of  the  Mucos.v  over  a  Submucous  Myoma 312 

201.  A  Small  Myoma  Pushing  through  the  Mucosa 3L3 

202.  Thinnixg-out  of  the  Mucosa  over  a  Submucous  Myom.\ 313 

203.  Atrophy  of  the  Mucosa  over  a  Submucous  Myoma 314 

204.  Marked  Thinning-oi  r  ok  the  Mucosa  over  a  Submucous  Myoma 314 

205.  A  Submucous  Myoma  almost  Devoid  of  Mucosa 315 

206.  Marked  Thickening  of  the  Uterine  Mucosa  in  a  Depression  between  Myo.matous 

Nodules 315 


XVI  LIST    OF    Tl.LrSTKATIOXS. 

Fi<:.  Page 

207.  CJlaxi)  Hypehtroi'hy  ix  a  Clkkt  hetweex  Mvomakhs  Nodiles 316 

208.  Marked  Dilat.\tion  of  the  Veins  of  the  Uteium;  .Micosa 318 

209.  He.mohuhage  into  the  Utekine  Mucosa 319 

210.  Hemorrh.wje  into  the  Mucosa 319 

211.  Rupture  with  Subsequent  Thromrosis  of  a  Vein  of  the  Tterixe  Mucosa  over 

A  Submucous  Myo.m.v 319 

212.  Branching  of  a  Uterine  Gland 320 

213.  An  Atypical  Uterine  Gland 320 

214.  An  Unusual  Uterine  Gl.\nd 320 

21o.  Marked  Branching  of  a  Uterine  (!land 321 

•_M(i.   M MiKi.i)  Bkaxchi.vg  of  a  Uterine  Gland 321 

_M 7.   IIdk.ma  of  the  Uterine  Mucosa 322 

2 15.  Dilated  Uterine  Glands  over  a  Submucous  Myoma 323 

219.  Marked  Dilatation  ofthe  Uterine  Glands  over  a  Submucous  Myoma 323-324 

220.  Markedly  Dil.vted  Uterine  Glands 324 

221.  A  Moder.vte  Grade  of  Dilatation  of  the  Glaxds 325 

222.  Three  Small  Poylpi 326 

223.  Small  Uterixe  Polypi 326 

224.  Poly'pi  Associated  with  Uterixe  Myomata 327 

225.  A  Very  Early  Stage  of  a  Uterine  Polyp 328 

226.  The  Beginning  of  a  Uterine  Polyp 328 

227.  A  Uterine  Polyp 329 

228.  Cross-section  of  a  L.\rge  Uterine  Polyp  in  a  Case  of  Multiple  Myomata 330 

229.  Cross-section  of  Very  Large  Uterine  Polyp  in  a  Case  of  Myo.ma 330 

230.  A  Very  LAR(iE  Uterine  Polyp 331 

231.  A  Myoxlv  Oricixatixg  in  the  Uterine  Mucosa 333 

232.  Polypoid  Endometritis  and  Double  Pus-tubes  Associated  with  a  My'oma  of  the 

Fundus 334 

233.  TuBERcixosis  OF  the   Exdometkh'm    and    Fallopian   Tihes   Associated   with   a 

Myomatous  Uterus 336 

234.  A  Myomatous  Uterus  Associated  with  Pyosalpinx 338 

235.  A  Tubo-ovarian  Cyst  Associated  with  a  Myomatous  Uterus 339 

236.  A  Tubo-ovarian  Cy'st  and  Dense  Adhesions  Complicating  a  Myomatois  Utkhcs  .  339 

237.  A  My'o.ma  of  the  Right  Fallopian  Tube 340 

238.  Ruptured  Tubal  Pregnancy  Co.mplicating  Uterine  Myomata 341 

239.  The  .Median  End  of  a  Fallopi.vn  Tube  App.\rently  Terminating  in  a  Myoma 343 

240.  A    .MlLTILOCULAR    OVARIAN    CySTADENOMA   ASSOCIATED    WITH    A    MULTINODULAR    MyO- 

M.\Tous  Uteri's 345 

241.  A  Multiplicity'  of  Pathologic  Coxditioxs 346 

212.  Ax  Ovarian  Cyst  with  I'.aki.v  Pai'ii.i.ahv  M.vsses  Associated  with  ^Iultiplk  Uter- 
ixe Myo.mata 347 

243.  .\  Der.moid  Cyst  Associ.vted  with  a  Myomatous  Uterus 349 

244.  A  Multinodular  Myomatcjus  Uterus  with  a  Parovarian  Cyst  on  the  Right  and  a 

Der.moid  of  the  Left  Ovary' 350 

245.  A  Very  Large  Left  Ovary  Associated  with  a  Myom.vtous  Uterus 351 

246.  A  Gre.\tly  Lengthened-out  Ovary  A.ssociated  with  Uterlne  Myom.vi'a 352 

247.  The  Coalescence  of  a  Subperito.neal  Pedunculated  Myoma  with  an  Ovary 353 

248.  Cy.ST  of  the  UtERO-OVARIAN  LlCiA.MENT 356 

249.  Cysts  in  the  Utero-ox' arian  Li(l\ment 357 

250.  Myoma  of  the  Utero-ovauiax  Lig.vment 359 

251.  Myoma  of  the  Right  Utero-ov.\rian  Ligament 360 

252.  Myoma  of  the  Utero-ovariax  Ligament 361 

253.  Myoalv  of  the  Round  Fkiamkni' 362 

254.  A  Myoma  Lying  Free  from  the  Uterus  and  Situated    hetwee.v   the  Tube  and 

Ovary 363 


LIST    OF    ILLUSTRATIONS.  XVll 

Fig.  Page 

255.  A  SuBVE.sicAL  Myo.ma 365 

256.  A  Bladder  Forced  out  of  the  Pelvis  by  .\n  Incarcerated  Myomatous  Uterus.  .  .   365 

257.  A  Bl.\dder  Carried  as  High  as  the  Umbilicus  by  a  Large  Mygm.ytous  Uterus  . . .   366 

258.  A  Bladder  Adherent  to  Two  Myomatous  Nodules 367 

259.  Adhesions  between  the  Bladder  and  a  My'om.\tous  Uterus 367 

260.  Adhesions  between  the  Bladder  and  the  Myomatoi^s  Uterus 368 

261.  M.vrked  Upward  Displace.ment  of  the  Bladder 369 

262.  The  Bladder  Lifted  High  into  the  Abdomen  by  a  Myomatous  Uterus 369 

263.  Dislocation  and  Dilatation  of  a  L^reter  due  to  a  Large  Myomatous  Uterus 378 

264.  Myoma  in  the  Broad  Ligament  Displacing  the  Right  Ureter  Upward  and  For- 

w.^rd 379 

265.  Dislocation  Upward  and  Forward  of  the  Left  Ureter  by  a  Myo.matous  Uterus    379 

266.  Marked  Dislocation  of  the  Ureters  where  the  Abdomen  was  Filled  avith  a 

Myom.\tous  Uterus 380 

267.  Hydroureter  Due  to  Pressure 381 

268.  Displaced  Right  Ureter  Mi.st,\ken  for  a  Dilated  Yei.\;   Ligated  and  Cut;   Suc- 

CESSFi'L  End-to-side  Anastomosis 383 

269.  Dense  Adhesions  Between  the  Sigmoid  and  a  Myxomatous  Uterus 386 

270.  Dense  Adhesions  of  the  Sigmoid  Flexure  .\nd  of  a  Loop  of  Small  J^owel  to  a 

X  Tubo-ovarian  Abscess 387 

271.  An  Extensive  Rectal  Tear 388 

272.  A    MXTLTINODULAR  MYOMATOUS    UtERUS,  COMPLICATED    BY    AX    OVARIAX    CyST    OX    THE 

Right  and  a  Densely'  Adherent  Tubo-ovariax  Abscess  ox  the  Left 389 

273.  A  Tubo-ovarian  Abscess,  Densely  Adherext  to  the  Sigmoid  Flexi're 389 

274.  C.\RCIXOMA  OF  THE  SiGMOID  FlEXURE  ASSOCIATED  WITH  A  MYOMATOUS   UtEIUS 393 

275.  Myomata  IX  Old  Age 395 

276.  Squa.mous-celled  Carcinoma  of  the  Cervix  Associated  with  Multiple  Uterixe 

Myomata 399 

277.  C.\RCixoMA  of  the  Bl.\dder  Secoxdary  to  Squamous-celled  Carcinoma   ok   ihk 

Cervix 401 

278.  IxvAsiox  OF  A  Myoma  by  a  Squamous-celled  Carcixoma  of  the  Cervix 403 

279.  Adexocarcixom.\  ix  a  Myoma,  Secondary'  to  Adexocarci.noma  of  the  I^ody  of  the 

Uterus 407 

280.  A  Large  Myo.m.\tous  Uterus  Choking  the  Pelvis;  Small  Ovarian  Cysts  on  Both 

Sides;    Thickening  and   Retr.\ction  of  the  Omentum.     Metastasf.s   in  the 
Liver  Second.\ry  to  an  Adenocarcinoma  in  the  Body'  of  the  Uterus 409 

281.  An  Enlarged  MYOM.vrous  Uterus.     Adenocarcinoma  of  the  Body  of  the  Utkius. 

P.VPILLOCYSTO.MAT.\    OF    BoTH    OvARIES,    WITH    KxTKXSION     HV    CoNllNiriY     I'o     IHF. 

Inguinal  Glands 11- 

282.  Calcification  of  tiik  IIkakt  Muscle  Associated  with  Uterine  Myomata 121 

283.  Hyaline  Degeneration  of  Heart  Muscle,  As.sociatei)  with  riKuiNK  .Myomata.    .  425 
281.  A  Very  Early  Myoma. 431 

285.  Ax  Early  Myoma 432 

286.  An  Early  Myoma 433 

287.  The  Ahdo.mi.nal  Contour  Caused  by  a  Globular  Myomapoi-s  U^terts 437 

288.  The  Abdomi.val  Contour  Caused  by  a  Miltinodilau  Myomatois  Utkrcs 438 

2S!).   ^Lvl{KKD  F]lo.\(;atio.\  of  the  SuPRAVA(iiXAi.  i'oiMioN  oi    I  UK  ('ki;\  l.\ 442 

290.  .\  Myomatous  Uterus  Closely  Rkse.mblin(;  a  ruKiiNANi  I'lKia  s  ix  its  General 

CoNi'oru 468 

291.  .\  .M Yo\K\i()i's  rTEUFs  Hesk\iiu.i\<;  a  P'etus  i\  its  Contoku l(t<) 

292.  Till';  l'i;i!KOK.\  TKi)  IMiK(;N.\Nr  I'li.in  s  a.s  Seen  on  1\i:\io\  ai,  171 
2'.)'A.   A  I'ltKcv  \\t  rrEUKs.  wki  ii   i  iik  Fetus  and  Placent.v  Intact 172 

291.    .\ni)0\nN.\I,    I'RE(i.\AN(V    OK    I'oKK   YeARS'    Dl'UATIO.V 476 

295.  A  Ri'PTi'RED  CoRNi'Ai-  Pkegnancy 479 

296.  Rupture  of  the  Right  Cornu  of  a  Bicor.vate  I'terus  with  Ivscape  of  the  Fetus  ...    481 


XVIU  LIST    OF    ILLUSTRATIONS. 

Fig.  Page 

297.  A  Small  Fhag.mknt  ok  a  H vdatidikohm  .Molk 482 

298.  Chorio-epitheliom.\ 484 

299.  Carcixo.ma  of  the  Cervix  and  Lower  Part  ok  the  Body  of  the  Uterus  Clinically 

Resembling  .\  Myom.\tous  Organ 486 

300.  A  SuBMUcors  Myom.a.  Cli.vically  Suggesting  C.vrctnoma  of  the  Cervix 487 

301.  Adenocarcinoma  of  the  Body  of  the  Uterus  with  Subperitoneal  Nodules 488 

302.  A  Rare  Form  of  Adenocarcino.ma  of  the  Uterus 490 

303.  A  Pkculiar  Arrange.ment  of  Muscle-fibers  Suggestive  of  Carcinoma 491 

304.  Sarcoma  of  the  Body  of  the  I'terus 492 

305.  Sarcom.v  of  the  Body  of  the  I'terus 493 

306.  Fibroma  of  the  Ovary 494 

307.  A  Myomatous  I'terus  Mistaken  for  an  Ovarian  Cyst 496 

308.  A  MULTILOCULAR  OVARI.\N  CyST  IN  FoR.M   RESEMBLING  A  CySTIC  MyOMA 497 

309.  Bil.\teral  Ovarian  Cysts  with  Papillary  Masses  on  their  Surfaces 498 

310.  S.mall  Uterine  Myomata;    Carcinoma  of  the  Ovary  with  Very  Large  Omental 

Met.\stases 499 

311.  Tumor  of  the  Sigmoid  Flexire  Due  to  Rupture  of  Rectal  Diverticula  into 

the  Surrounding  Adipose  Tissue;   Small  Pelvic  Abscess 501 

.'^12.  Retroperitoneal  Sarcom.\ 502 

313.  A  Pedunculated  Subperitone.\l  Myoma 508 

314.  A  Large  Subperitoneal  Myoma 508 

315.  A  Difficult  Myomectomy' 511 

316.  Abdo.minal  Enl.\rgement  Due  to  a  Cystic  Myoma 513 

317.  Cross-section  of  a  Cystic  Myoma  Weighing  89  Pounds 515 

318.  Multiple  Myomectomy' 516 

319.  Myomectomy  or  Hysterectomy 519 

320.  The  First  Steps  in  Abdominal  Myomectomy 520 

321.  Kelly-Cullen  Myoma  Enucle.\tor 521 

322.  Shelling  the  Tumor  out  of  the  Uterine  Wall 522 

323.  Obliteration  of  the  Sp.\ce  in  the  Uterine  Wall  after  Removal  of  the  Myo.ma  ....  523 

324.  Appe.\ran'ce  of  the  Uterus  after  Abdominal  Myomectomy' 524 

325.  Uterine  Myo.ma  Complicated  by  a  Three  and  One-half  Months'  Pregnancy- 530 

326.  Multiple  Myomectomy  on  a  Woman  Three  Months  Pregnant 530 

327.  A  Subperitoneal  Myoma  Complicating  Pregnancy 531 

328.  Myoma  of  the  Cervix  Ob.stkucting  the  Vagina  and  Complicating  a  Four  Months' 

Pregnancy 532 

329.  A  Myom.\  of  the  Bro.vd  Lig.\.ment 554 

330.  Pelvic  Adhesions  Following  Abdomin.\l  Myomectomy 557 

331.  Appearance  of  x  Uterus  Five  Years  after  Removal  of  a  Laiige  Interstitial 

Myom.v 562 

332.  Myomata  Re.muveu  by  Abdominal  Myo.mecto.my 563 

333.  A  Uterus  about  Six  Years  after  Abdo.minal  Removal  of  a\a.  .Mvom.vta  that 

could  be  Detected 564 

334.  A  Large  Submucous  Myom.\ 573 

335.  A  Submucous  Myoma  Gre.\tly  Distendlng  the  Vagina 573 

336.  Vagi.n.\l  Bisection  of  a  Submucous  Myom.\ 574 

337.  Method  of  Removing  x  Very  Large  Submucous  My().\l\ 574 

338.  Method  of  Delivering  .\  Very  Large  Submucous  Myoma 575 

339.  vSuTl'RE  OF  THE  CeRVI.X  .\FTER  REMOVAL  OF  A  SUBMUCOUS  MyOM.V 575 

340.  Appearance  of  the  Cervix  .\fter  Removal  of  a  Submucous  Myoma  that  had  been 

Attached  to  the  Vagin.\l  Portion  of  the  Cervix 576 

341.  A  Very  V.\scul.\r  Sloughing  Submucous  Myoma 583 

342.  A  Gauze  Swab  Found  in  the  Cavity  of  a  Myomatous  Uterus 588 

343.  A  Myomatous  Uterus  .\fter  Years  of  Electric  Tre.\tment 589 

344.  The  Myo.matous  Uterus  Prior  to  Removal 591 


LIST    OF    ILLUSTRATIONS.  XIX 

Fig.  Page 

345.  Amputation  Through  the  Cervix 592 

346.  The  Appearance   of  the  Pelvis  when  all  the  Cardi.nai.   \'f,sskls   have   heex 

Clamped  and  the  Tumor  Removed 593 

347.  The  Uterus  as  it  Appears  on  Removal  when  all  the  Vessels  have  been  Con- 

trolled WITH  Clamps  and  Cut 595 

348.  Appearance  of  the  Pelvis  after  all  the  Cardinal  Vessels  have  been  Controlled    596 

349.  Drawing  the  Uterine  Vessels  into  the  Cervical  Stump 597 

350.  Insertion  of  the  End  of  the  Round  Ligament  into  the  Cervical  Stump 598 

351.  Appearance  of  the  Pelvis  after  Supravaginal  Hysterectomy 599 

352.  Appearance  of  the  Pelvis  after  Insertion  of  the  Round  Ligament  into  the 

Cervical  Stump 600 

353.  Extensive  Removal  of  the  Cervical  Mucosa  where  Supravaginal  Hysterectomy 

is  Performed 601 

354.  Extensive  Removal  of  Cervical  Mucosa 602 

355.  A  Diagrammatic  Representation  of  the  Left  to  Right  Operation 606 

356.  Bisection  of  the  Uterus 609 

357.  First  Steps  in  Bisection  of  the  Uterus 610 

358.  Bisection  of  the  Uterus 611 

359.  Bisection  of  the  Uterus 612 

360.  Bisection  of  the  Uterus 613 

361.  Bisection  where  the  LTterus  Completely  Fills  the  Pelvis 614 

362.  The  Value  of  Bisection  of  the  LTterus 615 

363.  Transverse  Section  of  the  Cervix  as  the  First  Step  in  Hystehomyomectomy 616 

364.  Abdominal  Hysteromyomectomy  "from  Below  Upward" 617 

365.  Appearance  of  the  Pelvis  after  Complete  Hysterectomy 618 

366.  A  Large  Raw  Area  Left  after  Removal  of  a  Cystic  Myoma 619 

367.  Method  of  Controlling  a  Bleeding  Area  where  a  Needle  Cannot  be  Safely 

Employed 620 

368.  Temporary  Control  of  Bleeding  from  a  Subperitoneal  Pedunculated  M  voma  ....  621 

369.  Method  of  Establishing  Vaginal  Drainage 624 

370.  An  Indication  for  Abdominal  Instead  of  Vaginal  Hysteromyomectomy 628 

371.  A  Myomatous  LTterus  Accurately  Filling  the  Pelvis 630 

372.  An  Incarcerated  Myomatous  Uterus 630 

373.  Retroperitoneal  Development  of  Myomata 631 

374.  A  Very  Difficult  Hysteromyomectomy 632 

375.  A  Myomatous  Uterus  Blocking  the  Pelvis 633 

376.  A  Myomatous  Uterus  that  Tended  to  Sag  Down  and  Completely  Fill  the  Pelvis  .  .  634 

377.  Leaving  the  Outer  Layers  of  the  Myoma  Attached  to  the  Bowel 635 

378.  Method  of  Dealing  with  Extensive  Intestinal  Adhesions 635 

379.  A  Large  Abscess  Lying  Anterior  to  a  Myomatous  Uterus 636 

380.  Circumscribed  Abscess  in  the  Omentum  Associated  with  a  Densely  Adheuf.nt 

Myo.matous  Cterus  and  an  Ovarian  Abscess G3S 

381.  A  Longitudinal  Section  OF  the  Abdomen  Showing  an  I'.mbilical  Hernl\,  a  Lahgk, 

De.nsely  Adherent,  Myomatous  Ftekus,  and  an  Ovarian  Abscess (HO 

382.  A  liARfJE  Peuuncul-vted  Subperitoneal  Myo.ma  Compmcatinc;  I'regnancv 643 

383.  A.  Normal  Precjnancy  A.s.sociated  with  a  Large  Subperitonkal  .Myoma 644 

384.  A  Pregnant  Multinodular  .Myomatous  Uterus 645 

385.  Pregnancy  in  a  Multinodular  Uterus 647 

386.  An  Early  Prf:gnancy  in  a  Myomatous  Uterus 651 

387.  A   PuRULE.NT  Accumulation    in  the  Cervical  Stump   Following   Supravaginal 

Hysterectomy 664 

3SS.   Dii.AiiNc;  \  Cervix  to  Kkmove  a.n  AccuMri.ATinN   of  Frs  between   the  Ckkvical 

Stump  a.nd  the  Pelvic  I'euitonei'm ()64 


MYOMATA  OF  THE  UTERUS. 

CHAPTER   I. 
UTERINE  MYOMATA.- 

Uterine  niyuiiiata  in  the  beginning  are  usually  interstitial,  but  in  time  tend  to 
force  their  way  to  the  outer  surface,  becoming  subperitoneal,  or  toward  the 
uterine  cavity,  eventually  becoming  submucous.  Should  they  pass  out  between 
the  folds  of  the  broad  ligament,  they  develop  into  intraligamentary  myomata, 
and  those  starting  near  the  cervix  may  l^ecome  essentially  cei-vical  myomata. 

When  the  nodule  passes  to  the  outer  surface  of  theuterusit  may  remain  firmly 
fixed  and  is  spoken  of  as  a  sessile  myoma,  in  contradistinction  to  one  that  has 
become  pedunculated.  In  Fig.  1  is  represented  a  sessile  myoma  projecting  from 
the  right  of  the  uterus,  and  attached  to  the  fundus  is  a  pedunculated  myoma. 
The  pedicle  of  the  myoma  consists  of  utei'ine  nuiscle  and  carries  the  blood-vessels 
for  the  tumor.  The  myoma  itself  may  be  enveloped  in  a  thin  covering  of  uterine 
muscle,  or  the  normal  muscle  may  cover  it  only  in  the  vicinity  of  the  pedicle. 

The  subperitoneal  myomata  may  reach  almost  any  size  and  maybe  lobulated 
or  smooth.  The  smaller  ones  are  usually  smooth.  Occasionally  we  find  a 
myoma  presenting  a  particularly  rough,  volcanic-looking  appearance  and  very 
hard  on  pressure.  Such  a  myoma  has  no  outer  capsule  of  normal  muscle  and  is 
very  dense.  Fig.  2  shows  an  excellent  example  of  a  niulbei-ry-shaped  myoma. 
It  is  pedunculated  and  very  nodular,  while  the  remaining  myomata  are  sessile 
and  more  or  less  spheric. 

On  section,  the  myomata  are  very  firm.  They  an>  glistening  white  oi' whitish 
yellow  in  appeai'aiice,  and  ai'c  conqxtscd  of  biintllcs  of  libei-s  iHinning  in  all  dii'ec- 
tions.  As  a  rule,  they  can  be  (>asily  shellecl  out  from  the  surrounding  muscle,  a 
fact  that  renders  a  myomectomy  the  operation  of  choice  in  suitable  cases.  The 
myomata  stand  out  in  shai-p  conti-ast  to  the  surrouniling  uterine  muscle,  as  seen 
in  Fig.  'A.  Tiie  contrast  between  the  myoma  and  the  muscle  is  \-ei-y  shai'p  in  the 
cut  sjH'cimeii,  as  the  myoma  remains  the  same,  while  the  \iterine  muscle  con- 
tracts, lea\iiig  the  luiiior  standing  out  in  relief. 

*  Myoiiiat.-i.  (iliniinyi)m:il;i.  Ill  )n  >in:il  :i ,  ami  lil)n)i(ls  of  I  lie  uterus  an-  used  as  syuoiiyiniius  Icnus 
ami  nicau  prccisriy  llic  same  lliiiii;.  (  »!' coiii-sc.  in  ^ninc  inyninala  tin-  muscular  lissuc  prcdonii- 
iiatc^.  ill  otiicis,  t  lie  (iiirou.s  tissue  \\  r  lia\i'  iicscr  seen  a  I  rue  lilinuiia  n|'  the  uterus,  tliat  is, 
a  Uterine  tumor  consisting  entirely  of  lil)rous  tissue.  l''roni  tlie  patiiolouist 's  staml|ioiiit  tlie 
term  myoma  seems  the  ])referal)le  one.  Ciinicaiiy,  eaeh  of  tliese  terms  i-  so  lirmly  lixed  that  it 
is  hanlly  m'ee--sary  to  m,-ike  any  eli.iiiL;!-  in  tlie  designation. 
1  1 


MVO.MATA    OF    THH    ITKRUS. 


Pedicle 


Fig.  1.— Sessile  and  Pedunculated  Myomata.     (i  nat.  size.) 
San.  No.  1530.     Path.  No.  6479.     The  uterus    has  been  amputated  through  the  cervix.     Toward  the  right, 
at  the  junction  of  the  cer%'ix   and  body,  i.s   a   broad-based  sessile   myoma.     Springing  from  the  fundus    near  the 
origin  of  the  right  tube  is  a  pedunculated  and  slightly  subperitoneal  myoma.     The  appendages  are  normal.    With 
our  present  knowledge  the  ovaries  would  have  been  left. 


^"^'ivVf  .*  I'll  i     ,. 


Vu;.  2. — Mulberry-shaped  and  Sessile  My'o.ma.     (3  nat.  size.) 
Gyn.  No.  10403.     Path.  No.  6618.     Occupying  the  fundus  are  several  globular  sessile  nodules.     Projecting 
toward  the  |)03terior  surface  is  a  markedly  nodular,  mulberry-shaped  myoma,  which  was  devoid  of  muscular 
covering  and  was  excessively  hard. 


/0^' 


'^ 


'l/i    .-    .    fc'        1         ,  - 

ml-"-'-  '  h 


,^. 


UTERIXE    :\IYOMATA.  6 

Usually  nn'omata  are  discrete  and  sharply  defined,  Init  in  some  instances  we 
have  not  only  well-outlined  nodules,  but  also  a  general  myomatous  tendency. 
Such  a  condition  is  well  shown  in  Fig.  4.  The  surface  of  the  uterus  is  uneven, 
owing  to  the  presence  of  numerous  small  subperitoneal  myomata.  Near  the 
cervix,  and  also  at  the  fundus,  are  discrete  myomata,  while  the  outer  layers  of 
uterint^  muscle  from  cervix  to  fundus  are  composed  of  myomatous  tissue  only 
impei-fectly  divided  into  definite  myomata. 

Number  of  Myomata. — Before  operation  it  is  usually  impossible  to  tell  just 
how  many  myomata  the  uterus  contains.  Sometimes  it  may  be  the  seat  of  one 
small  or  large  tumor,  but 
very  frequentl}'  it  contains 
several,  and  in  a  few  cases 
the  uterus  may  l^e  literally 
riddled  with  tiunors,  as  in 
Gyn.  No.  12849. 

In  Case  4903  the  myo- 
matous uterus  filled  the 
lower  two-thirds  of  the  ab- 
domen and  32  myomata  were 
counted.  The  uterus  in  Case 
8354  contained  l:)etween  30 
and  40  nodules.  Such  large 
numbers  are  the  exception. 
The  uterus,  as  a  rule,  con- 
tains less  than  ten  myomata 
and  often  only  one  or  two. 

Size  of  Myomata.  —  The 
tumor  may  consist  of  the 
uterus  riddled  with  myo- 
mata, or  the  enlargement 
may  be  due  to  one  or  more 
interstitial  or  subj)eritoneal 
nodules.* 

In  afewof  our  cases  the  ulci'us  was  i-ciatix'cly  small  aiidoiieratioii  was  indicated 
for  the  loss  of  blood,  not  for  the  size  of  the  myoinata.  Small  subniucoiis  tumors 
at  times  give  rise  to  alarming  liciiioriiiagc. 

In  the  vast  majoritv  of  our  cases  the  l uinoi'  IiIKmI  the  |i('l\is  and  c\tcndc(l  into 
the  lowci"  aixloincn.  During  the  early  days  of  the  hospital  many  myomata  of 
large  jjroportions  were  cncountertMl.  I'oi-  example,  in  Case  3394  tlu>  tumor 
weighed  22  pounds;  in  Case  ()41S,  2'.l  pounds:  and  in  Case  3440,  30  ])ounds. 
The  invomatous  tumors  ni;i\-  not  onl\'  (ill  the  abdomen,  but  occasionallv  are  so 


Fi 


3. 


.\n  Ordinary  Mvomatovs  Utervs  ox  Section. 
(J  nat.  size.) 
CJyn.  No.  3985.  Path.  No.  986.  The  uterine  cavity  is 
relatively  small  and  has  been  encroached  upon.  Occupying 
the  upijer  part  of  the  body  are  nuinemus  myomata  of  various 
sizes  and  sh.ipes.  and  with  the  muscle  bundles  arranged  in 
\vh<irls  or  passing  in  almost  any  direction.  The  myomata  stand 
(lut  in  sharp  contrast  to  the  normal  muscle,  which  is  much 
darker  iti  color. 


*  In  ;i  fi'W  cases  the  iiiyi)ii:;itiiiis  iiicriis  .ii)]!:!!!'!)!  ly  inci'cascs  pfM'ccpl ii)ly  in  size  at    the  men- 
strual period.     'I'liis  was  |)articularly  ni)iieeal)ie  in  Cases  JlilT  anil  !)J'J1. 


MYO.MATA    OF    TllK    ITKHIS. 


large  that  tlioy  extend  ui)\var(l  hciicath  the  costal  inargiiis,  as  hi  Cases  4285  and 
6324. 

Myoniata  may  reaeh  tremendous  projjortions,  as  in  Case  ]\IeA.  (p.  512).  This 
j)ati('nt  was  operated  uj)on  by  one  of  us*  in  1906.  The  myoma  was  attached  to 
the  uterus  by  a  small  pedicle,  and  weighed  89  pounds.  It  had  received  the 
greater  part  of  its  iiouiishment  from  the  omentum.     As  far  as  we  can  learn  from 

the  literature,  it  was  the  largest 
myoma  ever  successfully  removed. 
Shape  of  the  Myomata. — A\']ien 
we  remember  that  myomata  may 
be  single  or  nmltiple,  that  they 
may  be  situated  in  any  part  of  the 
uterus,  and  may  be  small  or  reach 
very  large  ])ro]i()rtions,  it  is  clearly 
evident  that  the  uterus  or  the  myo- 
matous masses,  as  a  result  of  the 
a])normal  enlargement,  may  as- 
■^  siune  a  great  variety  of  shapes. 

Pear-shaped  Myomata. 
— AMien  the  uterus  contains  one 
large  interstitial  myoma  it  may  be 
pear-shaped,  and  resemble  in  con- 
tour a  pregnant  uterus.  (See  p. 
468.)  Case  2881  (Path.  No.  359) 
offered  a  very  good  example  of 
such  a  condition.  The  uterus  was 
pear-shaped  and  measured  31  x  28 
X  21  cm.  The  enlargement  was 
caused  chiefly  by  an  interstitial 
myoma,  19  x  20  x  23  cm.  Pear- 
^  ^  sha])ed  enlargement  of  the  uterus 

'Myomatous   Tkxukxcy."     (Nat.       .  i     ,•       i 

^i^^^  IS  relatively  common. 

Path.    No.    3601.     The    uterus    is    not    much    enlarged,  K  i  (1  U  C  y-  S  h  a  p  C  (1       111  y  O  - 

but  its  surface  is  nodular,  owing  to  the  presence  of  numerous  ,                              ±     ■     r                   i^                j. 

small     subperitoneal     myomata.     Nearly    all     the     uterine  HI  a  t  a      ai'C     UOt    lilt  IVqUent  ly    mct 

muscle  is  occupied  by  small  myomata,  or  its  fibers  show  a  with'       thcV     are     USUallv     SUl)])eri- 
definite  diflfuse  myomatous  tendency,    a  is  the  uterine  cavity. 

toneal  and  pedunculated,  and  are 
generally  associated  with  interstitial  and  submucous  nodules.  In  Case  3281 
the  uterus  contained  interstitial  and  subimieous  myomata,  while  projecting  from 
the  right  side  of  the  uterus  was  a  kidney-shaped  tumor,  9  x  10  x  18  cm.  On  the 
left  side  of  the  uterus  was  an  irregular,  kidnc^y-shajied  mass,  16  x  18  x  29  cm. 
I'he  concavity  of  this  mass  was  directed  toward  the  uterus. 

*  Thomas  S.  Cullcn,  A  Scries  of  Interesting  Gynecologic  and  Obstetric  Cases,  Jour.  A.  M. 
A.,  May  4,  1907. 


Fi<;.     4. — A     Gknkiial 


uterixp:  myomata.  5 

In  Case  3340  (Path.  No.  607)  the  uterus  was  10  x  11  x  12  ciii.  and  studded  with 
small  subperitoneal,  interstitial,  and  sul)niucous  niyoniata.  In  addition  there 
were  three  large  pedunculated  submucous  nodules,  a  mulberry-shaped  tumor 
13  cm.  in  diameter,  and  two  kidney-shaped  masses,  each  averaging  13  cm.  in 
its  longest  diameter.  One  was  situated  to  the  left,  the  other  to  the  right,  of  the 
uterus.     Kidney-shaped  subperitoneal  myomata  are  fairly  common. 

Heart-shaped  myomata  may  be  interstitial  or  subperitoneal. 
In  Case  3111  (Path.  No.  479)  th(>  uterus  was  9  x  9  x  10  cm.,  the  enlargement 
being  caused  by  small  myomata.  Springing  from  the  right  cornu  was  a  pedun- 
culated myoma,  4.5  x  5  x  7  cm.,  and  from  the  left  cornu  a  heart-shaped,  slightly 
lobulated  mass,  5.5  x  8  x  10  cm. 

In  Case  3199  (Path.  No.  524)  the  uterus  contained  several  myomata.  The 
anterior  wall  was  occupied  l)y  a  heart-shaped  myoma,  11  x  12  x  14  cm. 

The  pelvic  tumor  in  Case  3320  (Path.  No.  589)  was  13  x  21  x  28  cm.  and  heart- 
shaped.     Lying  on  its  anterior  surface  were  the  uterus  and  appendages  intact, 

M  u  1  b  e  r  r  y  -  s  h  a  p  e  d  m  y  o  m  a  t  a  are  subperitoneal  and  peduncu- 
lated and  may  be  small  or  large.  They  are  easily  recognized  by  their  globular 
form  and  rough  nodular  surface.     They  are  not  very  common. 

Projecting  from  the  myomatous  uterus  in  Case  2800  (Path.  No.  312)  was  a 
large,  mulberry-like  tumor,  12  x  19  x  19  cm.  This  was  covered  with  dense 
adhesions,  and  was  attached  by  a  pedicle  2  x  3  cm. 

The  uterus  in  Case  3340  (Path.  No.  607)  contained  subperitoneal,  interstitial, 
and  submucous  myomata.  One  of  the  three  pedunculated  sub{)(>ritoneal  myo- 
mata had  a  mulberry-like  surface  and  was  13  cm.  in  diameter. 

In  Case  3942  (Path.  No.  964)  the  pedunculated,  subperitoneal,  mulberry- 
like myoma,  8.5  x  11.5  x  12.5  cm.,  was  removed  and  the  uterus  saved. 

T  h  r  e  e  -  1  e  a  f  -  c  1  o  V  e  r  -  s  h  a  p  e  d  M  y  o  m  a  t  a. — In  Case  2718  (Path. 
No.  259)  the  uterus  viewed  from  the  front  resembled  in  form  an  immense  three- 
leafed  clover.     The  hilum  corresponded  to  the  sacrum. 

Saddle-bag  M  y  o  m  a  t  a. — Occasionally,  when  a  myoma  is  pn^sent  on 
either  side  of  the  uterus,  the  picture  suggests  a  saddle-bag.  In  Case  4845  there 
were  two  large  myomatous  masses,  one  on  either  side  of  the  uterus,  "giving  it  a 
saddle-bag  appearance."     Similar  pictures  were  noted  in  Cases  3689  and  6542. 

Sacral  Ma  r  k  i  n  g  s.  Occasionally,  where  the  luiiior  reaches  lai'ge  ])i'()- 
portions  and  still  lies  in  the  i)elvis,  it  may  rest  firmly  on  the  sacrum,  ll  will  then 
show  a  concavity  where  it  has  come  in  contact  with  the  sacral  promontory. 
In  Case  3130  (Path.  No.  499)  the  uteinis  contained  a  few  small  myomata. 
Springing  from  the  right  side  was  a  subperitoneal  myoma.  14  x  18  x  25  cm. 
Its  posterior  surface  presented  a  deej)  (lej)i-ession,  corresponding  to  the  jiromon- 
tory  of  the  sacrum.  On  either  side  of  this  depression  were  prominent  lobu- 
lations. 

In  Case  3440  (Path.  No.  674)  a  myoma  weighing  30  i)oun(ls  was  attached  to 
the  small  myomatous  uterus  by  a  pedicle  4  cm.  in  diameter.     The  under  surface 


6  :MY()M ATA    OF    THK    ITEIU'S. 

of  the  tumor  presented  a  (lej)ressi()ii  whieli  A\as  an  exact  counterpart  ot  the 
sacml  prominence. 

Pelvic  Mollis. — Whei'e  tiie  tumors  are  Hrmly  lixed  in  the  jielvis  and 
continue  to  enlarge,  they  may  finally  become  molded  to  the  form  of  the  j)elvis. 
In  Case  1767  the  uterus  contained  at  least  30  myoniata,  anil  filling  the  pelvis 
was  a  tumor  which  was  a  "true  cast  of  the  pelvis."  This  myoma  seemed  to  be 
made  up  of  a  great  mass  of  nodules  pressed  together. 

This  process  of  molding  was  also  noted  in  Cases  8882  and  F.,  C.  H.  I.,  August 
10,  1902. 

R  e  s  e  m  b  1  i  n  g  a  F  e  t  u  s.— The  resemblance  of  a  myomatous  utems  to 
a  fetus  is  described  on  page  469. 


(.Complete  erosion  of  mucosa 
vessels  of  capsule  exposed.. 

J"iG.  5. — IxJECTio.N'  OF  .\  Myom.\tous  Uterus.     (X  1?  diam.) 
The  uterus  after  injection  ha.s  been  cut  in  two.     The  uterine  walls  are  very  vascular,  hut  tlie  niyoinafa  in 
this  particular  case  show  practically  no  blood-supply.     The  uterine  mucosa  i.s  in  places  intact,  but  over  a  wide  area 
show.s  a  dpfinite  ero.sion.      l.Vftcr  ,Tohn  G.  Clark.) 

The  Blood-supply  of  Myomata. — This  sul)ject  has  been  very  satisfactorily 
worked  out  by  John  (1.  Clark,*  who  injected  a  large  number  of  myomatous  uteri. 
He  found  that,  taken  as  a  whole,  the  uterine  muscle  was  much  more  vascular 
than  the  myoniata. 

The  blood-.supply  of  the  myomata  is,  of  course,  derived  from  the  uterine 
muscle.  If  the  nodules  are  small,  the  blood-vessels  surrounding  them  are  cor- 
resjiondingly  small,  but  where  the  myomata  reach  very  large  proportions,  very 
large  blood-vessels  are  seen  passing  from  the  muscle  and  ramifying  over  the 
surface  of  the  tumor.  The  veins  may  reach  7  mm.  or  more  in  diameter.  The 
arteries  are  much  less  in  evidence. 

*  John  G.  Clark,  Tlie  Cause  and  Significance  of  Uterine  Heniorrliage.s  in  Ca.ses  of  Myoma 
Uteri,  Johns  Hopkin.s  Hosp.  Bulletin,  1899,  vol.  x,  page  11. 


UTERIXE    MYOMATA.  7 

If  the  myoma  is  a  very  large  tumor  with  a  thin  outer  covering  of  uterine 
muscle,  two  definite  vascular  systems  can  at  times  be  made  out,  the  one  supply- 
ing the  muscle,  the  other  forming  the  network  over  the  surface  of  the  tumor. 

A^'hen  an  injected  myomatous  uterus  is  cut  in  two,  the  contrast  between  the 
uterine  muscle  and  myomatous  tissue  is  very  sharply  defined.  In  practically 
all  cases  the  uterine  muscle  is  richly  supplied  with  blood.  In  some  the  myomata 
are  almost  devoid  of  vessels,  as  seen  in  Fig.  5,  but  not  infrequently  many  vessels 
are  scattered  throughout  the  tumors. 


•.H-.i>-- 


\^:!^- 


"S^^SH^v  '■ 


A-'i 


IT"--*' 


-v^' 


^^m^-::r,^^ 


':.  -:*«?_-: 


-.1^ 

-^^ 


Fio.  6. — Typical  Myomatous  Tissue.     (X  100  diam.) 
Gyn.  No.  2091.     Path.  No.  265§.     Scattered  throughout  the  fibrous-tissue  matrix  are  bundles  of  non-striped 
muscle-fibers  cut  longitudinally  and  transversely.     The  muscle  bundles  present  a  wavy  appearance.     The  nviclei 
of  the  muscle-fibers  are  sjjindle-shaped. 

\\'li(ii  the  iiiN'omata  arc  very  large,  veins  of  (■x('('])ti()iial  size  may  be  seen 
scattered  tliioughoiit  the  tumor.  In  Case  2881  (Path.  No.  359),  the  myoma 
measured  19  .\  20  .\  23,  and  thin-walled  veins  fully  8  mm.  in  diameter  were  found 
in  the  tumor.  Again,  in  Case  3440  (Path.  Xo.  <)74).  the  tumor  weighed  30  jKumds, 
and  there  were  slit-like  openings,  5  to  7  mm.  in  diameter,  in  its  substance.  These 
veins  closel)''  resembled  the  veins  of  a  livei-. 

Histologic  Appearances  of  Myomata. — Sections  from  myomata  are  remark- 
abl}'  uniform  in  their  ajjijearaiiee.     The  tis.sue  is  made  up  of  bundles  of  non- 


5  -MYO.MATA    OF    THE    rTERUS. 

striped  iiiusclc-tihcrs  cut  Iciiiithwisc  and  transversely.  These  bundles  may  t'orni 
graceful  curves,  be  perfect!}'  circular,  or  run  in  and  out  in  all  directions,  ^\'hcn 
the  niyoniata  are  young,  the  circular  arrangement  is  often  very  clearly  seen,  as 
in  Fig.  286  (p.  433).  In  the  very  small  myomata  the  tumor  consists  almost 
entirely  of  muscle,  but  when  it  reaches  1  cm.  or  more  in  diameter,  there  is  an 
admixture  of  muscle  and  fibrous  tissue.  Fig.  6  shows  the  characteristic  myoma- 
tous picture.  II(>re  longitudinal  and  cross-sections  of  non-striped  muscle  are 
found  scattered  'nreuularl\'  t  Inouii'liout   a  matrix  of  fibi'ous  tissue. 


h 


,if 


a  -  b  c 

Fig.   7. — Thk   Line  or  Clkavagk  Between   a  Myoma  and  the   Uterine  Muscle.      (X  55  diain.l 
Gyn.  No.  3008.     Path.  No.  435.     a  is  myomatous  tissue;    b  an  outer  and  rough  capsule  also  composed  of 
myomatous  tissue;    c  is  uterine  muscle.     At  d  is  a  definite  point  of  cleavage,  the  myoma  being  separated  from  its 
outer    myomatous    capsule    b.v  a  well-defined    space.     At  e  the    uterine   muscle   shows  a  definite  inflammator.v 
reaction. 


In  practically  all  myomata  that  reach  any  apj^reciable  size  hyaline  degenera- 
tion is  noted  in  the  librous  tissue,  in  the  muscle,  or  in  both.  As  a  rule,  the 
muscle-fibers  in  the  myoma  are  closely  packed  together  and  stain  somewhat 
more  deeply  than  the  suirounding  uterine  muscle. 

The  line  of  junction  l)etween  the  growth  and  the  uterine  muscle  is  usually 
not  only  sharply  defined,  but  there  is  a  definite  cleavage.  In  Fig.  7,  for  exam{)le, 
there  is  a  space  sej)ara1ing  the  myoma  from  the  uterine  wall.  There  are,  of 
course,  excei^tions  to  this  rule.  In  Fig.  S  the  myoma  is  sharply  differentiated 
from  the  muscle,  and  yet  they  are  so  insej)aral)ly  united  that  it  would  be  im- 
possible to  shell  this  tumor  out.     Occasionally  the  myoma,  instead  of  forming  a 


UTERINE    MYOMATA. 


9 


globular  nodule,  may  grow  out  irregularly  into  the  surrounding  muscle.     Such 
a  picture  is  ])resented  in  Fig.  9. 

Individual  Cells. — The  individual  nmscle-fibers  are  spindle-shaped.  The 
nuclei  are  long  and  narrow.  A\'hen  the  muscle-fiber  is  cut  through  at  its  center, 
we  see  a  small  spherical  mass  of  protoplasm  and  a  central  small  round  nucleus. 
If  the  cell  is  cut  obliquely,  it  may  appear  oval,  and  the  nucleus  also  ovoid,  in 
shape.  A  cross-section  of  a  muscle-fiber  near  the  end  will  yield  a  small  mass  of 
protoplasm,  devoid  at  this  point,  of  course,  of  a  nucleus.  Many  such  little  masses 
of  protoplasm  are  seen  in  the  nmscle  bundles.  When  the  muscle  nuclei  are  very 
closely  packed  together,  the  tissue  naturally  stains  more  deeply.  Nuclear  figures 
are  rarely,  if  ever,  seen  in  the  ordinary  myoma  stained  in  the  routine  manner. 


'«.,      '••(     V'  •»/»(|f'>'-^' 


Fr;.    N.         ULK.NUi.NO     Ut     A     M\OMA     W  I  1  H     Tilt     UTliRINK     MuiSCLK.       (.  X  1 00  clialU.  ^ 

Gyn.  No.  2570.  Path.  No.  162.  a  is  uterine  muscle;  b  very  cellular  myomatous  tissue.  The  line  of  junction 
is  very  sharply  defined,  but  there  is  no  point  of  cleavage,  the  myoma  merging  directly  into  the  uterine  muscle, 
c  is  a  blood-vessel. 

Professor  Mallory,*  of  Harvartl  University,  in  1904  described  several  new 
stains  by  means  of  which  he  was  able,  in  api)r()])riately  preserved  material,  to 
bring  out  clearly  the  neuroglia,  myoglia,  and  fibroglia  of  the  various  tumors. 
In  speaking  of  myoglia  he  says:  ''  The  study  of  a  series  of  leiomyomata  obtained 
chiefly  from  the  uterus  shows  that  while,  in  general,  the  sinooth-nmscle  cells 
closely  resemble  those  found  in  normal  tissues,  they  may  vary  considerably  in 
form  from  the  normal  tyjM'.  For  exanijile,  a  leiomyoma  occasionally  occurs  in 
which  the  cells  are  very  long  and  thin  and  the  nuclei  are  the  slenderest  of  rods. 
In  still  other  cases  the  cells  are  shoiM  and  thick  and  the  iniclei  have  a  long  or 
short  oval  form.     This  difference  in  tiie  shape  of  the  cells  (h'pends,  in  })art  at 

*  F.  B.  Mallory,  A  Contribution  to  tiio  Classification  of  Tumors,  .Journal  of  Medical  Re- 
search, vol.  xiii,  January,  1905.  See  also  F.  B.  Mallory,  The  Results  of  the  Application  of  Special 
Histological  Methods  to  the  Study  of  Tumors,  .lour.  Kxpcr.  Medicine,  vol.  x.  No.  5,  September 
.5,  1908. 


10 


MYOMATA    OF   THE    UTERUS. 


least,  on  the  raj)idity  of  firowth  of  the  tiiinor.     In  general  it  niay  ])e  said  thai  th(> 
slowest  growing  smooth-muscle  cells  are  the  most  slender." 

"The  myoglia  fibrils  in  the  tumors  vary  somewhat  in  number  and  coarseness, 
but  always  form  a  well-marked  and  characteristic  feature  of  the  cells.  As  in 
iioiiiial  tissue's,  they  remain  closely  applied  to  the  cell  columns;  so  far  as  can  be 
dclcrmincd.  they  do  not  leave  the  surface  of  cell  protoplasm  and  mix  with  the 
intercellular  connective-tissue  fibrils  surrounding  the  smooth-muscle  cells. 
The  iiiyogHa  fibrils  show  a  certain  tendency  to  twine  together,  especially  in  tissue 


Fig.  9. — The  Irrkgular  Extension  ok  a  Myoma  into  the  Utkrine  Muscle.    (X70diam.) 
Gyn.  No.  5010.     Path.  No.  1536.     Projecting  into  the  field  from  the  left  lower  corner  and  occupying  the 
middle  is  myomatous  ti-ssue,  recognized  by  the  dark  stain.     Its  confines  are  indicated  by  a.     At  b  are  a  few  isolated 
myomatous  bundles.     The  remaining  tissue,  which  stains  palely,  is  uterine  muscle. 


which  is  somewhat  edematous,  so  as  to  form  what  seem  to  be  unusually  coarse 
fibrils.  This  appearance  is  most  marked  at  the  ends  of  cells,  where  they  arc 
drawn  out  thin,  so  that  the  fibrils  running  from  one  cell  to  the  ne.xt  are  brought 
into  close  a])p()sition." 

In  oi'der  that  the  myoglia  may  be  carefully  studied,  small  ])ieces  must  be 
immediately  j)laced  in  Zenker's  fluid.  In  the  ordinary  routine  laboratory 
examination,  as  u.sually  carried  out.  it  is  im])ossible  to  detect  the  finer  structures 
of  the  mu.scle-fiber. 


utp:rixk  my():\iata. 


11 


Fig.    10. — A    Tr.^nsverse    Section     thuoigh 
A  Myom.vtous  Uterus. 
Gyn.    No.    2881.     The    uterus    was    pear- 


Position  of  the  Body  of  the  Uterus. — The  position  will  (li'iu'iul  iip(jii  the  size 
and  situation  of  the  niyomata.  If  they  are  of  .^^mall  size  and  seattered  uniformly 
throughout  it,  the  organ  retains  its 
normal  position  (Fig.  10).  If  a  myoma 
develops  from  the  upper  part  of  the  uterus, 
the  normal  relations  of  the  uterus  may 
still  be  maintamed.  If  a  myoma  develops 
in  the  posterior  wall,  the  fundus  may  be 
pushed  forward  toward  the  symphysis;  if 
the  myoma  originates  in  the  anterior  wall, 
the  fundus  may  be  forced  back  into  Doug- 
las' sac. 

"When  a  myoma  develops  in  the  lateral 
w'all  and  spreads  out  into  the  broad  liga- 
ment, the   uterus  will    usually  be   forced  to       shap'dV'si  x  28  xTl"cm.      The  transverse  sec- 
the  ODDOSite  side   (Fis!    11)  ^'""^    '^^^    been    made    just    above    the    ovaries. 

1    •     1  "^^^  uterine  cavity  is  surrounded  by  myomatous 

U  hen    the    mVOmata    are   multiple    and        tissue.     The  greater  part  of  the  uterine  muscle 
reach    large    proportions,     the    uterus    may       j^^jread  ou^t^over  the  surface  of  the  myoma  in  the 

rest  like  a  cap  on  the  top  of  the  tumor,  as 

noted  in  Cases  3133  and  8344.     Sometimes  the  uterus  is  so  hidden  between 

myomata  that  it  is  difficult  to  find,  as  in  Case  10403.     In  Case  McA.,  in  which 

an  S9-pound  subperitoneal,  pedunculated  myoma 
!^.    ,broad  Lig.  ^^'^^  reiiioved,  the  utcrus  lay  behind  the  tumor  and 

near  the  liver. 

Condition  of  the  Uterine  Muscle. — If  the  myo- 
mata are  small,  or  if  the  tumors  are  subperitoneal 
and  pedunculated,  the  uterus  is  usually  normal 
in  size,  but  when  it  contains  several  myomata, 
tliere  is  commonly  an  increase  in   size.     This  in- 

FiG.  11.— The  Myomatous  Uterus     d'casc  Is  Undoubtedly  causcd  by  the  iiiyoiiial :i ,  as 

AS  Viewed  on  Transverse  Sec-  •  i  i  i       j_i       r       ,   i  i      j   i  i  i  i  ,• 

evidenced  by  the  tact  that  the  enlarged  uterus,  alter 
the  myomata  have  been  removed,  gradually  under- 
goes involution  until  it  becomes  normal  in  size. 
The  following  cases  clearly  ilhistrate  the  increase  in 
size  of  the  uterus. 

In  Case  5021  a  myoma,  7  \  11  \  11  cm.,  was 
remoN'ed  per  alxlonicH  fi-om  the  posterioi'  wall. 
The  uterus,  iinniedi.-ilcly  alter  reino\-aI  of  ihe 
tumor,  was  two  and  one-half  times  its  natural  si/e. 
The  smooth-walled  uterus  in  Case  *.)'J21  reached 
neaiiy  to  the  unihilicus.  .\n  in  t  erst  ilia  I  myoma, !)  \  10  cm.,  was  renioNcd  from  the 
right  cormi.  The  utei'us,  after  ivmoxal  of  the  tumor,  was  between  two  and  three 
tim(>sits  natiu'al  size.      .\t  the  end  of  three  weeks  it  was  little  Iai'i;ei-  than  normal. 


TION  THROUGH   THE   CeRVIX. 

Gyn.  No.  701.  The  cervix  on 
section  looks  normal.  Attached  to 
it  on  the  right  is  a  portion  of  (he 
myoma,  which  extends  out  into  the 
broad  Hgament.  From  the  sketch 
it  is  seen  that  the  myoma  projected 
deeper  into  the  pelvis  than  did  the 
cervix. 

With  a  myoma  in  this  i)o.sitioii 
the  left  to  right  oi)erution  would  \  iclil 
the  best  results.  Much  care  wouM 
be  necessary  to  avoid  iiij\iry  to  the 
right  ureter. 


12  MVOMATA    OF    TIIK    rTF.Rl'S. 

\\'h('n  the  iii^'oiiiatous  uterus  is  \-('r}'  lar<2;(',  the  blood- vessels  are  naturally 
much  increased  in  size  and  tlie  uterine  nuiscle  is  very  vascular. 

Occasionally  the  uterine  muscle  may  undergo  partial  hyaline  degeneration, 
as  noted  in  Case  2S52.  The  globular  utems  was  13  x  13  x  14  cm.,  the  chief 
increase  in  size  being  due  to  the  j)resence  of  a  degentM'ated  and  interstitial  myoma 
12  cm.  in  diani(>ter.  The  uterine  muscle  was  considerably  altered.  The  muscle- 
bundles  were  separated  from  one  another  l)y  hyaline  material  containing  only  a 
few  nuclei.  The  individual  muscle-fibei-s  aj)peared  to  have  undergone  this 
hyaline  change.     In  other  jjortions  the  muscle  appeared  normal. 


CHAPTER  II. 
PARASITIC  UTERINE  MYOMATA. 

Myomata  that  have  for  some  reason  become  ])artially  or  ahiiost  eoiii- 
pletely  separated  from  the  uterus  and  receive  their  main  l:)loo(l-!?upp]y  from 
another  source  may  be  termed  parasitic. 

Uterine  myomata  at  first  obtain  their  entire  nourishment  from  the  uterus, 
but  may  in  time  derive  the  greater  part  of  it  from  (1)  the  omentum;  (2)  the 
Fallopian  tubes;  (3)  the  mesenteric  vessels;  (4)  the  large  or  small  intestine: 
(5)  the  bladder;  (6)  the  abdominal  wall;  (7)  the  broad  ligament;  (8)  several  of 
these  sources  at  the  same  time. 

We  are  here  chiefly  interested  in  the  role  that  the  omentum  plays  when  the 
myoma  gradually  changes  its  source  of  blood-supply.  Our  own  observations 
have  satisfied  us  that  the  omentum  is  the  guardian  of.  the  abdominal  organs. 
In  many  cases,  when  myomata  exist,  the  omental  adhesions  are  associated  with 
dense  pelvic  adhesions  or  with  pus-tubes.  Here  it  is  perfectly  natural  that  the 
omentum  should  become  firmly  adherent.  Of  special  interest  is  that  grou]i  of 
cases  in  which  the  tubes  and  ovaries  are  comparatively  normal  and  offer  no 
particular  incentive  for  the  omental  adhesions,  and  yet  in  which,  for  some  reason, 
the  omentum  manifests  a  certain  affinity  for  the  subpc^-itoneal  and  usuall>- 
pedunculated  nodule,  becomes  adherent  to  it,  and  soon  furnishes  a  large  part  of 
its  sustenance.  Sometimes  only  a  few  vessels  pass  from  the  omentum  to  the 
myoma,  as  in  Fig.  24  (p.  34),  where  four  vessels  are  seen  entering  a  jkhIuiicu- 
latccl  nodule.  As  the  jK'diclc  of  the  tumor  becomes  small(>r  and  its  original  source 
of  nourishment  diminishes,  the  omentum  sends  in  more  and  more  vessels,  as 
seen  in  Fig.  13  (p.  17),  Fig.  14  (p.  17).  Fig.  15  (p.  18),  and  Fig.  Ki  (p.  19). 
These  vessels  may  spread  out  over  the  siui'acc,  divide  into  smaller  brandies,  and 
then  enter  the  tumor,  as  shown  in  Fig.  18  (p.  22)  and  Fig.  20  (j).  25);  or  they 
may  plunge  at  once  into  the  depth,  as  is  shown  in  Fig.  24  (ji.  34).  .\s  a  nih'. 
we  have  found  large  arteries  accompanied  by  two  veins.  The  Ncins  in  some 
instances  reach  t  i'enien<lous  pi-o|»oilioiis.  In  Case  C.,  Ilagerstow  ii.  toi'  instance, 
some  of  them  were  iiioi'e  than  1  eiii.  in  diameter  and  looked  lii\e  sniaH  snakes. 

CHANGES   IN   THE   OMENTUM. 
The  function  of  the  onientuni  can  l)e  most  i)eautifully  followed  in  these  cases. 
If  it  be  called  upon    for  a  small    l)lood-suiii)ly.  a  few  \-essels  are  at  once  sent   in 
and  but  little  change  is  noted  in  the  oiiientuin.      lint  when  the  t  unioi'  is  large  and 

i;; 


14  MYOMATA    OF   THE    rTEHUS. 

much  is  rc(|uir('(l  of  the  oinciitiini,  the  vessels  rajjidly  increase  in  size  and  the 
oiiiciital  fat  iiiathially  disappears.  This  gradual  absorption  of  fat  is  well  fol- 
lowed in  Fig.  17  [\).  20),  Fig.  18  (p.  22),  Fig.  20  (p.  25),  Fig.  21  (p.  26), 
Fig.  23  (p.  29),  and  Fig.  24  (p.  34).  The  first  change  noted  is  that  the  vessels 
in  the  vicinity  of  the  tumor  stand  out  clearly,  and  that  the  tissue  between  the 
vessels  is  becoming  rarefied.  Later,  the  vessels  near  the  tumor  are  mcn^y  sup- 
ported by  the  peritoneal  folds  of  the  omentum.  The  fat  continues  to  be  absorbed 
until  little  or  no  trace  of  omentum  remains,  and  the  vessels  are  only  recognized 
as  omental  on  account  of  their  relation  to  the  transverse  colon.  This  is  strik- 
ingly well  shown  in  Fig.  25  (p.  36),  in  which  a  small  fringe  of  fat,  1  cm.  broad 
and  lying  against  the  transverse  colon,  was  all  that  remained  of  the  omental 
adipose  tissue. 

The  omental  vessels  seem  to  have  an  unlimited  capacity,  as  in  Case  C.  (p.  24), 
in  which  a  very  large  myoma  with  a  small  pedicle  existed.  Here  not  only  was 
there  a  liberal  su))])ly  of  omental  nourishment  for  the  upper  surface  of  the 
tumor,  but  the  omentum  had  sent  down  a  bunch  of  vessels  to  its  lower  pole. 
These  vessels  formed  a  cord  6  cm.  in  diameter.  They  were  held  together  by 
peritoneum,  but  wei'e  free,  the  only  fixed  points  being  their  points  of  origin  at  the 
transverse  colon  and  their  disappearance  into  the  lower  end  of  the  tumor.  At 
operation  we  lifted  this  cord  up,  completely  encircling  it  with  the  hand.  It 
looked  just  like  a  bunch  of  small  snakes.  One  isolated  omental  vessel  lay  ab- 
solutely free  for  a  distance  of  IS  cm.  The  function  of  the  omentum  is  certainly 
marvelous,  as  can  be  seen  on  reference  to  Case  McA.  (p.  512).  Here  the  subper- 
itoneal tumor  weighed  89  pounds  and  was  attached  to  the  uterus  by  a  pedicle 
1  X  1.5  cm.  in  diameter.     The  chief  nourishment  had  come  from  the  omentum. 

In  rare  instances  the  myoma  becomes  completely  separated  from  the  uterus 
and  rc^ceives  its  entire  nourishment  from  the  omentum.  Such  an  example  is 
furnished  by  Case  14709  (see  Fig.  23,  p.  29). 

Lymphatics. — AMien  large  myomata  exist,  dilated  hmphatics  are  often 
found  in  the  broad  ligaments.  It  is  but  natural  that  with  the  increased  activit}' 
of  the  omentum  its  lymphatics  also  should  be  increased  in  size. 

In  Fig.  17  (p.  20)  there  is  marked  dilatation  in  the  broad  ligament  lymphatics, 
as  is  indicated  at  a,  and  coursing  down  the  omentum,  which  is  densely  ad- 
herent to  the  pedunculated  myoma,  are  markedly  dilated  and  tortuous  lymph- 
channels. 

In  Fig.  18  (p.  22)  the  omentum  is  rapidly  losuig  its  fat,  and  its  peritoneum 
is  disappearing,  leaving  oval  clear  spaces.  At  e  is  a  very  large  tortuous  lymph- 
channel.  As  a  rule,  these  large  lymph-vessels  collapse  soon  after  remo\al  and, 
therefore,  frecjuently  escape  observation  in  the  laboratory. 

Etiology. — The  cause  seems  inherent  in  the  myomata  and  not  in  the  sur- 
rounding organs.  The  uterus  is  naturally  trying  to  get  rid  of  its  interstitial 
nodules,  and  they  conse(iuently  become  subnnicous  and  subperitoneal.  Now, 
when  a  myoma  becomes  subperitoneal,  the  continued  uterine  contraction  grad- 


PARASITIC    UTERIXE    :MY()MATA. 


15 


iially  renders  it  pcdunculatt'd,  and  finally  the  mere  -weight  of  the  nodule  making 
traction  on  the  pedicle  will  still  further  attenuate  it.  Owing  to  the  diminished 
blood-supply,  these  nodules  are  usually  prone  to  degenerate,  and  often  show 
hyaline  degeneration  or  necrosis.  The  peritoneal  surface  develops  a  slight 
roughening,  and  the  omentum  at  once  becomes  adherent. 

If  this  reasoning  be  true,  we  would  naturally  expect  the  part  of  the  tumor 
farthest  away  from  the  pedicle  to  sufTer  first.  A  reference  to  Fig.  13  (p.  17), 
Fig.  14  (p.  17),  Fig.  15  (p.  18),  Fig.  16  (p.  19),  Fig.  17  (p.  20),  Fig.  18  (p.  22), 
Fig.   20   (p.   25),  and  Fig.   25   (p.  36)  will  show   that   in  each  of  these  cases 


b-M'T 


„  .'  ;-"?-5,^'«*''7..-:",!.'.,,...v-  ft-''; 


v.^:*^. 

»  * 


W^W^'"^'^ 


5.^.'.Tr  £" 


'.  Z'-^  ■  ■•.'■•■■■■ 


^^^ff:^' 


Vic.  12. — Omkntal  Blood-vksski.s  that  ark  Keeping  Alive  the  Outer  Layers  of  a  Myoma  which  Shows 
ALMOST  Total  Hyaline  Degeneration.  (X  80  diameters.) 
Gyn.  No.  11S98.  Path.  No.  8284.  The  myoma  was  enveloped  in  omentum  and  was  attached  to  the  uterus 
by  a  pedicle  1  cm.  in  diameter.  The  appendages  were  normal.  Microscopically,  the  tumor  showed  marked  hyaline 
degeneration  and  coagulation  necrosis,  as  well  as  areas  of  calcification  (Fig.  101,  p.  12S).  a  indicates  the  outer  con- 
fines of  the  hyaline  degeneration;  h,  the  remaining  outer  zone  of  myomatous  tissue;  and  c,  tlic  limits  of  the 
adherent  omentum.  To  the  left  the  omental  fat  is  still  seen,  but  toward  the  right  it  has  been  entirely  replaced 
by  fibrous  tissue  and  many  new  and  relativelj-  large  blood-vessels. 

the  omental  vessels  entered  the  tiiiiior  ai  liie  point  most  distant  from  ils 
connection  with  the  uterus.  The  omentum  appears  I o  be  fullilling  its  normal 
useful  function  of  guardiiiii;  othei-  abdominal  organs  from  danger.  If  the 
omentum  does  lu^t  furnish  the  myoma  with  the  necessary  nourishment,  the  lat- 
ter may  develop  an  abscess  in  its  interior  and  open  into  the  intestine  (as  seen  in 
Fig.  32,  p.  46),  or  else  it  may  become  a  parasite  U|)on  the  intestines  or  bhidder 
for  its  sustenance. 

Special  Points  in  the  Operative  Treatment  when  Large  Omental  Adhesions  Exist. 
— Naturally, the firstthingtodoafter  oi)ening  the  abtlomen  will  be  to  control  the 


16  :myomata  of  the  uterus. 

omental  vessels.  We  always  make  it  a  point  to  tie  off  the  omental  vessels  twiee 
on  the  proximal  and  once  on  the  distal  or  tumor  side.  These  vessels  are  so 
delicate  and  tear  so  easily  that  we  invariably  tie  instead  of  clamping  and  then 
tying.  The  mere  weight  of  the  artery  forceps  is  at  times  sufficient  to  tear  them, 
and  serious  hemorrhage  may  follow. 

Since  it  is  of  the  greatest  im])ortance  to  always  tie  under  sight,  the  incision 
must  he  sufficiently  long  to  enable  the  operator  to  see  all  the  vessels  clearly. 
A\'hcii  the  omental  adhesions  extend  over  a  wide  area,  the  incision  may  be 
gradually  lengthened  as  is  found  necessary,  but  an  attempt  should  never  be  made 
to  liberate  adhesions  far  up  under  the  abdominal  wall,  as  they  may  contain  large 
veins  or  arteries. 

In  Case  McA.  (p.  512),  in  which  the  tumor  weighed  89  pounds,  these  precau- 
tions were  strictly  ol^served,  and  yet  the  tumor  was  everywhere  so  intimately 
attached  that,  notwithstanding  our  care,  a  small  piece  of  liver  came  away  with 
it.  If  a  careful  and  methodic  tying  of  the  omental  vessels  be  practised,  even  the 
largest  tumors  may  often  be  removed  with  a  loss  of  not  over  two  ounces  of  blood. 

Fig.  22  (p.  28)  gives  a  very  good  idea  of  the  huge  congeries  of  omental  ves- 
sels that  the  operator  will  occasionally  encounter. 

Cases  in  which  the  Omentum  Affords  Part  of  the  Blood-supply  to  Parasitic 
Myomata. — This  condition  is  relatively  common.*  AVe  have  picked  out  a  num- 
ber of  the  more  characteristic  cases,  so  that  the  various  and  progressive  changes 
in  the  omentum  can  be  clearly  followed. 

Gyn.  No.  694. 

A  multinodular  myomatous  uterus  with  a  partially 
p a  r a  s  i  t  i  c  m  y  o m a  ,  receiving  m  u  c  h  of  its  blood-  s  u  p p  1  }- 
from    the   o  m  e  n  t  u  m    (Fig.  13) . 

E.  P..  white,  single,  aged  thirty-six.  Admitted  April  23;  discharged  June  20, 
1891.     This  tumor  had  grown  rapidly  and  had  almost  completely  filled  the  ab- 

*  All  the  following  37  cases  showed  verj-  extensive  omental  adhesions.     In  the  25  designated 
by  an  asterisk  the  myomata  were  partially  parasitic. 
Gyn.    No.  .51.5*  Gyn. 

'"       "      660* 

"      694*  '' 

"  "  1.38.3^* 

"  "  2800* 

"  "  ,3216 

"  "  3296* 

"  "  3.387* 

"  "  .3440 

"  "  3.5.58* 

"  "  3842 

"  "  39.50* 


Mo.  ,3974* 

Gyn. 

No.  12139 

''      4293 

"  121,5,5* 

"   4869 

"  12216 

"   ,5,392 

"  12696* 

"   ,5784* 

"  12738* 

"   6367 

"  12864 

"   6432 

"  13023* 

"   7220 

"  13039* 

"   7549* 

"  C.  H.  I.  (P.), 

"   7739* 

Hagerstown  (C.).* 

"   9027* 

Frederick  (B.).* 

"   9078* 

"  11898* 

TARASITIC    UTERINE    MYOMATA, 


17 


(loiiicii  after  one  year.  It  had  been  first  noticed  two  years  ])reviously.  Opera- 
tion, May  2,  1891.  Supravaginal  hysterectomy.  The  omental  adhesions  were 
tied  off  and  the  uterus  was  removed.  The  patient  made  an  uninterrupted  recov- 
ery. The  chief  interest  centered  in  the  large  subperitoneal  and  pedunculated 
myoma,  which  had  several  omental  vessels  entering  through  its  upper  surface. 

Gyn.  No.  3950. 

Double  h  }'  d  r  o  s  a  1  p  i  n  X  ;  left  ovarian  abscess,  ^^•  i  t  h 
d  e  n  s  e  a  d  h  e  s  i  o  n  s .  A  p  e  d  u  n  c  u  1  a  t  e  d  a  n  d  p  a  r  t  i  a  1  1  y 
p  a  r  a  s  i  t  i  c  m  y  o  m  a  ,  r  e  c  e  i  v  i  n  g  most  of  its  1)  1  o  o  d  -  s  u  ])  - 
ply    from    the    omentum    (Fig.  14). 


Fig.  13. — A  Partially  Parasitic  Myoma  Receiving 
MOST  OF  its  Blood-supply  from  the  Omentum. 
Gyn.  No.  694.  This  sketch  represents  the  ap- 
pearance at  operation.  The  uterus  is  much  enlarged. 
Above  the  right  tube  is  a  globular  tuuKjr,  and  above 
and  to  the  left  is  a  pedunculated  nodule  receiving  the 
greater  part  of  its  nourishment  from  the  omentum. 
The  parasitic  vessels  are  relatively  very  large  and  the 
omental  fat  has  disappeared. 


Fig.  14. — A  Partially  Parasitic  Myoma  Receiving 
A  Large  Blood-supply  from  the  Omentum. 
Gyn.  No.  3950.  The  uterus  is  relatively  normal 
in  form,  .\ttached  to  its  posterior  surface  by  a  nar- 
row pedicle  is  a  globular  calcified  nodule.  Its  entire 
upper  surface  is  covered  by  omental  vessels,  which 
spread  out  over  its  peritoneal  covering.  Both  Fal- 
lopian tubes  are  the  seat  of  a  hydrosalpinx  and  the 
left  ovary  has  been  converted  into  a  large  abscess 
which  is  densely  adherent  to  the  rectum. 


M.  E.,  colored,  married,  aged  thirty-seven.  Admitted  Xovemhcr  *.);  dis- 
charged December  IS,  IS!).").  The  })atient  has  had  two  cliildreii,  the  youngest 
seven,  also  one  miscarriage.  Five  years  ago  she  noticed  a  small  luiiior  in  the 
right  inguinal  region.  Only  for  the  })ast  yar  has  it  been  })ainful  and  tender: 
it  was  movable  at  first,  but  has  been  adherent  for  the  last  five  months.  She  has 
a  constant  dull  aching  pain  at  the  umbilicus. 

Operation,  November  14.  ISO,').  Hysteromyoniectoiny.  There  were  general 
pelvic  adhesions.  Attached  to  the  ]-)0st(Mior  snrtaee  oi  the  uterus  by  a  sniall 
pedicle  was  a  calcified  myoma,  receiving  nmcli  of  its  nut  lit  ion  from  l  lie  adherent 
omeiituni  (big.  II).  Faeli  tube  was  the  seat  of  a  li\(lrosalpin\  and  the  left 
ovary  had  been  conN'erted  into  a  lai'ge  abscess.  The  patient  made  a  satislaetoi'V 
recovery. 


18 


MVOMATA    OF   THK    ITERUS. 


Gyn.  No.  3558.     Path.  No.  742. 
A   p  a  r  t  i  a  1  1  y    p  a  r  a  s  i  t  i  c    111  y  o  in  a  .    r  c  c  c  i  v  i  n  o;  most   of  its 
n  o  II  r  i  s  h  111  e  n  t     f  r  o  111    t  h  v    o  111  c  11  t  u  111  :    n  o  r  111  a  1    u  t  c  r  u  8    a  n  d 
a  ])  J)  ('  11  (I  a  g  V  .s    (Fi^.  15). 

1;.  H.,  white,  siiiiilc.  a.iicd  thirty-two.  Aihnittcd  June  3;  discharged  June 
29,  lS9o.  Five  years  ago  her  menstrual  How  l)egan  to  be  profuse  and  her  phy- 
sician told  her  that  she  had  a  tumor.  The  abdomen  is  tender  and  she  has  sharp 
pains  throughout  it. 

Operation,  .lune  6,  1S95.  Myomectomy.  Attached  to  the  right  cornu  by  a 
long  slender  jK'dicle  was  a  myoma,  9x9  cm.,  movable,  non-adherent  except 
posteriorly  to  tiie  vermiform  appendix,  to  which  it  was  attached  by  light  vela- 

mentous  adhesions,  and  anteriorly  to 
the  onientuni,  which  sent  in  several 
large  vessels  (Fig.  15).  The  patient 
made  an  uninterrupted  recovery. 

Path.  No.  742.  The  specimen  con- 
sists of  an  irregular  globular  tumor,  9 
x  9  x  8  cm.,  covered  over  an  area 
measuring  7x7  cm.  with  adhesions. 
Some  of  these  contain  fat  and  are  un- 
doubtedly omental.  The  large  tumor 
on  section  is  pearly  white  in  color  and 
is  traversed  by  numerous  yellowish- 
white,  slightly  translucent  areas. 
Along  one  margin  it  contains  an  area 
of  degeneration  4x4  cm.  The  central 
])ortion  of  the  growth  is  brownish-gray 


Fig.     15. — A    Large    Pedunculated     Myoma    Rf> 

CEIVING      nearly       ALL        OF      ITS        BlOOD-SUPPLY 
J-ROM    the    OmENTU.VI. 

Gyn.  No.  3558.  The  sketch  represents  the  ap- 
pearance as  seen  at  operation.  The  uterus  and  appen- 
dages are  normal.  Attached  to  the  right  cornu  by  an 
unusually  long  and  slender  pedicle  is  a  myoma  which 
has  received  nearly  all  its  blood-supply  from  the  omen- 
tum. As  seen  from  the  history,  the  myoma  showed  i  i  •  i 
considerable  degeneration.  In  a  short  time  the  tumor  aiKi  the  lliarginS  shOW^  an  OrangC  COlor. 
would  probably  have  entirely  lost  its  connection  with 
the  uterus. 

fined  from,  and  are  much  softer  than. 


The  degenerated  areas  are  sharply  de- 
fined from,  and  are  much  softe 
the  surrounding  tis.sue.     The  pedicle  of  the  tumor  is  1.5  cm.  in  diameter. 


Gyn,   No,   3974.     Path.   No.   980. 

S  u  ij  ])  e  r  i  t  o  n  e  a  1  a  n  d  i  11  t  e  r  s  t  i  t  i  a  1  \i  t  e  r  i  n  e  m  y  o  m  a  t  a  ; 
1  a  r  g  e  s  u  b  p  e  r  i  t  o  n  e  a  1  n  o  d  u  1  e  ,  j)  a  r  t  i  a  1 1  y  p  a  r  a  s  i  t  i  c  an  d 
receiving  its  main  blood-supply  from  the  omentum 
(Fig.  16). 

.M.  \\'.,  colored,  single,  aged  thirty.  Adinitte*!  Xoveniber  19;  discharged 
December  28,  ]S<)5.  Three  years  ago  the  j)atient  noticed  an  al)doniinal  enlarge- 
ment, first  on  the  left  side.  The  tumor  apparently  disai)peared  for  six  months, 
evidently  because  it  had  been  dislodged.     It  reappeared  and  gradually  increased 


m  size 


PARASITIC    ITKRIXE    MVOMATA, 


19 


Operation,  Novonihcr  20,  1895.  Hystei'oiiiyonict'tomy.  Through  an  in- 
cision 20  cm.  in  length  a  lai'ge  myoma,  springing  from  the  h'ft  horn,  was  dehvered. 
The  highest  post-oi)erative  temperature  was  101. o"  on  ihc  second  day. 
Recovery  was  complete. 

Path.  No.  980.  The  specimen  comprises  the  uterus  with  its  ap])endages  and 
two  large  pedunculated  tumors.  The  uterus  is  irregular  and  nodular,  approxi- 
mately 7  X  5.5  X  5  cm.  Its  surface  is  covered  with  a  few  vascular  adhesions, 
and  presents  numerous  l^osses  and  pedun- 
culated nodules,  varying  from  1  to  3  cm.  in 
diameter.  Springing  from  the  left  cornu  is  a 
pedunculated  tumor  9  cm.  in  diameter,  and 
from  the  right  side  of  the  wall  a  tumor,  25 
cm.  in  diameter,  and  attached  by  a  pedicle 
3  cm.  broad  (Fig.  16).  The  larger  tumor  for 
the  most  part  is  smooth  and  glistening,  but 
presents  an  area  of  omental  adhesions,  12  x  8 
em.  These  adhesions  consist  of  a  large 
number  of  blood-vessels  surrounded  by  a 
small  amount  of  connective  tissue.  The 
uterine  walls  are  occupied  by  numerous  firm 
nodules,  varying  from  0.5  to  3  cm.  in  dia- 
meter. All  the  nodules,  both  interstitial  and 
subperitoneal,  present  the  typical  myomatous 
appearance.     The  uterine  cavity  is  6  cm.  in     F"--  i6.— a  very  large  subperitoneal 

,  .  ,  1        (•         1  1   •  ■'^^'^     Pedunculated    Myoma,    Receiv- 

length,  3  cm.  m  breadth  at  the  fundus,  and  is  ing  most  of  its  nourishment  from 

THE  Omentum. 

Gyn.  No.  3974.  The  sketch  was  made  at 
operation.  The  uterus  contains  several  small 
myomata,  and  the  appendages  are  normal. 
Attached  to  the  fundus  by  a  short  pedicle  is  a 
myoma  2.5  cm.  in  diameter.  Over  an  area 
12  X  S  cm.  the  omentum  is  densely  atlherent. 
The  omental  vessels  are  large  and  tortuous, 
and  are  so  intimately  blended  with  the  myoma 
that  they  might  readily  be  mistaken  for  nor- 
mal instead  of  adviMititiDUs  vessels. 


distorted.  The  mucosa  varies  from  1  to  4 
mm.  in  thickness.  It  is  smooth  and  glisten- 
ing, but  shows  some  hemorrhage. 


Gyn.  No.  3296,     Path.  No.  580. 

A  large  su  b  p  c  i' i  t  o  n  c  a  1  jx'dun 
C  u  1  a  t  e  d  a  n  d  p  a  r  a  s  i  f  i  c  m  y  o  in  a 
s  h  o  w  i  11  g       111  u  (•  h       (1  e  g  e  11  e  ]•  a  t  i  o  n 

an  d   re  c  e  i  v  i  n  g  m  o  s  t  of  its  n  o  u  r  i  s  h  m  c  11  t    f  ro  m   t  h  c   o  m  e  11  t  u  111 
(Fig.  17). 

M.  W.,  white,  married,  aged  forty-one  Aihiiiltcd  .lanuaiy  28;  disch.irgcd 
March  6,  1895.  The  ])atient  has  been  inari'lcd  liftccii  ycai's,  has  had  two  childi'cn 
and  one  miscan'iagc  The  menses  began  at  eighteen  and  wei'e  I'egiilar  excry  four 
weeks  until  recently.  .\o\\  the  peiiods  occur  e\eiy  two  weeks.  I'or  two  years 
the  abdomen  has  been  steadily  increasing  in  size,  and  al  present  a  large  hard  mass 
can  be  readily  felt  through  the  alxlominal  walL 

()pei'atioii,  .Ianuar\'  30,  1805.  ilysteroniyoniectomy.  ( )n  section  of  the 
abdomen  a  large  sessih',  subserous  myoma  with  a  ])edicle,  (i  \  I  cm.,  was  found. 


20 


MYO.MATA    OF    THK    ITF^RI'S. 


The  whole  transverse  breadth  of  the  oiiiciituni  was  adherent  to  tlie  tumor  and 
sent  large  vessels  mto  it  (Fig.  17).  The  omentum  was  tied  ofi'  and  the  uterus 
removed.  For  the  first  two  days  the  patient  ]3resented  an  almost  typical  picture 
of  hemorrhage,  ah  hough  neither  dressings  nor  incision  showed  any  oozing. 
The  temperature  rose  to  102.0°  on  the  second  day,  the  j)ulse  to  IIS.  She  then 
commenced  to  ini]irove,  the  temperature^  drop])iiig  to  normal.     After  removal 

of  the  stitches  for  some  vmac- 
couiitable  reason,  the  tem))er- 
ature  rose  to  104.2°  and  the 
l)ulse  to  120,  but  on  the  fif- 
teenth day  the  former  dropped 
to  100°  and  reached  normal 
on  the  twenty-second  day. 

Path.  No.  580.  The  speci- 
men consists  of  the  uterus, 
tubes,  and  ovaries  and  a  large 
mass  springing  from  the  pos- 
terior surface.  The  tumor  is 
irregularly  oval  in  shape, 
27  X  23  X  16  cm.  Its  surface 
is  smooth  and  glistening,  ex- 
cept along  its  upper  portion, 
where  the  omentum  is  adher- 
ent over  an  area  measuring 
16  X  8  cm.  The  tumor  pre- 
sents numerous  bosses,  is 
pinkish    in   color,   and   along 

Fk;.  17. — A  \'kry  Large  Pedunculated  AND  Partially   NKfRoTic        •>  <■  i  • 

.Myoma,  Receiving  A  Rich  Blood-supply  FROM  THE  Omentum.  ^tS    SUrtaCC    many  large   VCmS 

Gyn.  Xo.  3296.     The  sketch  indicates  the  appearance  at  opera-        Ml'e   SCCU     the   largest    of    thcSG 
tion.     The  uterus  itself  is  normal.     In  the  right  broad  ligament  are 
large  and  tortuous  vessels  (a),  filled  with  clear  or  milky  fluid.     These 
are  markedly  dilated  lymph-channels. 

The  large  pedunculated  myoma  attached  to  the  posterior  sur- 
face of  the  uterus  is  27  x  2.3  x  16  cm.  in  its  various  diameters.  At- 
tached to  its  entire  upper  surface  is  omentum  which  distributes 
numerous  blood-vessels  to  the  tumor.  The  large  tortuous  and 
white  vessels  (b)  projecting  from  the  transverse  colon  are  dilated 
lymph-channels. 


being  6  mm.  in  diameter. 
The  tumor  is  firm,  but  some- 
what yielding,  and  on  section 
is  dirty  grayish  yellow  in 
color  and  has  whitish  bands 
traversing  it  in  all  directions. 
These  divide  the  tissue  up  into  large  and  small  lobules.  In  a  few  places  are 
eircum.scribed  masses  of  bright  yellow  material  I'esembling  fat,  and  in  some  por- 
tions of  the  tumor  are  s))aces  reaching  3x2  cm.,  wiiich  are  divided  up  into  smaller 
ones  by  delicate  trabecuhe  and  contain  a  clear  transparent  fiuid.  Scattered 
thnjughout  the  tumor  are  many  hlood-vessels  AN'hich  have  \'erv  delicate  walls. 
The  uterus  presents  nothing  of  interest.  On  the  right  side  the  vessels  of  the 
])arovarium  are  greatly  enlarged,  and  the  parovarian  tissue  is  edematous.  The 
ovary  is  normal.     On  the  left  side  the  appendages  are  unaltered. 


PAKASITIC    UTERINE    MYOMATA.  21 

Histologic  Examination. — The  mucosa  is  edematous,  and  in  some  places  the 
glands  can  be  traced  a  short  distance  into  the  muscle.  The  large  tumor  spring- 
ing from  the  uterus  is  composed  of  non-striped  muscle-fibers  cut  longitudinally 
and  transversely.  It  has  a  fairly  abundant  blood-supply,  and  scattered  through- 
out it  are  irregular  patches  of  hyaline  degeneration.  The  yellow  patches  seen 
macroscopically  are  nothing  more  than  large  areas  showing  typical  hyaline 
change.  In  the  vicinity  of  these  the  non-striped  muscle-fibers  often  appear  un- 
altered or  may  stain  deeply;  they  end  abruptly,  being  replaced  by  finely  fibril- 
lated  hyaline  material.  In  other  portions  the  tissue  has  undergone  coagulation 
necrosis  and  there  is  considerable  nuclear  fragmentation.  At  such  points  there 
is  hemorrhage  into  the  tissue  and  rows  of  resistant  muscle-fibers  can  still  be 
made  out.  There  is  a  moderate  polymorphonuclear  infiltration.  In  this  case 
abscess  formation  would  certainly  have  occurred  in  a  short  time. 


Gyn.  No.  7220.     Path.  No.  3476. 

A  large  pedunculated  parasitic  and  partially  c  3'  s  t  i  c 
myoma,  deriving  its  b  1  o  o  d  -  s  u  p  p  1  y  a  1  m  o  s  t  e  n  t  i  r  e  1  y 
from   the  o  m  e  n  t  u  m  (Fig.  18). 

E.  C,  white,  aged  fifty,  married.  Admitted  September  20;  discharged 
October  14,  1899.  The  patient  has  had  four  children  and  two  miscarriages. 
She  ceased  to  menstruate  one  year  ago.  The  abdomen  is  obliciuely  distended. 
The  tumor  takes  up  the  entire  right  half  and  lower  left  half  of  the  abdomen. 

Operation,  September  25,  1899.  Myomectomy.  After  the  omental  adhe- 
sions had  been  freed,  the  tumor  was  readily  separated  from  the  uterus.  The 
patient  had  a  postoperative  temperature  of  102.8°  on  the  sixth  day.  She 
made  a  satisfactory  recovery. 

Path.  No.  3476.  The  specimen  consists  of  a  large  subi)eritoneal  myoma,  ovoid 
in  shape,  19  x  14  x  12  cm.  Its  surface  for  the  most  part  is  covered  with  ad- 
hesions. The  anterior  and  upper  surface  presents  a  large  area  of  omental  tid- 
hesions,  covering  about  half  the  anterior  surface  (Fig.  18).  These  adhesions 
contain  numerous  large  blood-vessels,  which  branch  over  the  surface  of  tiie 
tumor.  There  are  also  large  lymph-vessels.  One  of  these  is  dilated  (7  mm.  in 
diameter),  and  filled  with  clear  fluid.  It  is  very  tortuous,  and  resembles  a 
ground-worm  in  its  convolutions.  On  ])ressure  the  tumor  is  in  i)ai't  lirni,  l)iit 
contains  an  area  of  fluctuation.  On  section,  it  is  found  tliat  the  entire  mass  has 
undergone  more  or  less  cystic  degeneration.  In  sonic  parts  small  delicate 
septa  divide  up  the  cystic  spaces.  The  pedicle  is  1.1  cm.  in  diameter,  and  con- 
tains verv  large  vessels.  The  specimen  is  a  typical  example  of  a  parasitic 
myoma. 

On  histologic  examination  the  myoma  pi'esents  lai'ge  areas  of  niaii<ed  cystic 
change.  In  places  there  are  muscle-fibers  separating  the  alveoli.  In  other 
places  the  tissue  is  structureless  and  is  liciuefying. 


Fig.  is. — A  Parasitic  Myoma   REfF.ivixo  a   Largk   Bi.ood-sipply  from  thk   O  mkntim.     Partial  .\trophv 

OF    THE    O.MENTAL    FaT 

Gyn.  No.  7220.  The  .sketch  \va.s  made  immediately  after  operation.  The  uterus  i.s  normal  in  size,  .\ttached 
to  the  fundus  by  a  short  slender  pedicle  is  a  myoma  19  x  14  cm.  Covering  the  entire  upper  surface  of  the  tumor 
are  omental  adhesion.'^,  and,  a«  seen  from  the  pathologic  report,  the  greater  part  of  the  myoma  has  undergone 
hyaline  and  cystic  degeneration. 

The  picture  well  depicts  the  gradual  atrophy  of  the  adipose  tis.sue  that  follows  when  many  omental  ves.sel.s 
are  connected  with  a  tumor.  .At  a,  normal  omentum  is  seen;  at  b  the  blood-ves-sel  has  lost  its  adipo.se  covering 
and  stands  out  clearly.  In  the  lower  part  of  the  omentum  all  trace  of  fat  has  disappeared  (c),and  nothing  but  the 
peritoneal  layers  of  omentum  and  the  vessels  remain.  At  d  the  vessel  is  very  clearly  seen.  At  numerous  points 
even  the  peritoneum  is  giving  way,  clear  spaces  resulting.  In  one  of  these  is  a  large  tortuous  vessel  (e)  filled  with 
clear  fluid.     It  is  a  much  dilated  lymph-vessel. 


PARASITIC    UTKRIXE    .MYOMATA. 


23 


Gyn.  No.  13039.     Path.  No.  10039. 

S  II  1)  p  e  r  i  t  o  11  I'  a  1  ,  interstitial,  a  n  d  .s  u  1)  111  u  c  o  u  s  u  t  e  r  i  n  e 
111  y  0  m  a  t  a  ;  111  a  r  k  c  d  a  trophy  of  the  o  m  e  n  t  u  111  as  a 
r  e  s  II 1  t  o  f  t  h  e  11  o  u  r  i  s  h  111  e  11  t  i  t  h  a  s  h  a  d  t  o  s  u  p  ply  to  the 
uterus  (Fig.  19). 

H.  H.,  colored,  aged  twenty-seven,  married.  Admitted  June  24;  discharged 
July  17,  1906. 

Operation,  hysteromyomectomy;  left  salpingo-oophorectomy;  right  salpin- 
gectomy. The  highest  postoperative  temperature  was  103.2°,  twenty-four  hours 
after  operation.     The  patient  made  a  perfect  recovery. 


Fig.  19. — Marked  Dis.\ppeara.\ce  oe  the  Fat  in  an  Adherent  (Jmextum.      (s  nat.  size.) 
Gyn.  No.  13039.     Path.  No.  10039.     The  left  tube  and  ovary  are  normal.     The  omentum  forms  a  mantle 
over  the  posterior  surface  of  the   nodular  myomatous  uterus,  between  a  and  a'.      In  most  places  nothing  but   the 
peritoneal  folds   of  the  omentum   remain,  giving  the  surface  of  the  uterus  a  rather  wrinkled  appearance.     Im- 
mediately around  the  blood-vessels,  however,  the  adipose  tissue  still  persists,  as  is  well  seen  at  b. 


Path.  No.  10039.  Tiic  uterus  has  l)ccn  aiiiputntcd  tiirough  the  cervix.  It  is 
9  cm.  in  lengtli,  7  cm.  in  hreadlh.  and  7  cm.  in  ils  anter()])()st(>ri()r  diaincttM'. 
It  is  everywhere  covere*!  wit  h  adhesions,  and  lias  a  lacework  of  oiiieiit  uin  attached 
to  it.  The  oiiientiini  is  atrophic  to  a  certain  extent .  and  the  fat  has  ahnost  en- 
tirel\'  disappeared,  l)Ut  still  persists  on  the  surface  of  the  uterus,  nlonii  the  course 
of  the  blood-vessels  (l''i,ii.  19).  This  fat  would  in  time  certainly  disai)pear. 
Scattered  throu<ihout  the  uterus  are  numerous  nodules,  some  of  them  not  o\'er 
2  mm.  in  diameter,  others  reaching  2..")  cm.  The  uterine  cavity  is  4  cm.  in  length. 
The  inuco.sa  is  hei-e  and  tiiere  gathered  up  into  little  domes:  in  other  woi'ds.  it 
shows  a  tendenc}'  toward  ])olypoid  formation.  It  vai'ies  from  2  to  1  mm.  in 
thickness. 


24  MYOMATA    OF   THE    I'TKRUS. 

Histologic  exaiiiiiiation  shows  that  the  mucosa  is  practicahy  nornuU.  In  sec- 
tions from  one  of  the  myomata  a  good  deal  of  hyaline  transformation  is  evident. 

This  case  exemplifies  how  the  omentum  atrophies  when  it  becomes  adherent 
to  the  uterus.  We  have  the  fat  disappearing  almost  entirely  except  in  the  im- 
mediate vicinity  of  the  blood-vessels. 

Path.  No.  7925. 

A  p  a  r  a  s  i  t  i  c  m  y  o  m  a  receiving  most  of  its  blood- 
s  u  J)  p  1  y  f  r  o  m  t  li  e  o  m  e  n  t  u  m  ;  m  a  r  k  e  d  d  i  s  a  p  p  e  a  ranee  of 
the   omental   fat     (Fig.  20). 

Mrs.  B.,  PVederick  Emergency  Hospital,  October  30,  1004.  The  patient  was 
forty-five  years  of  age,  and  had  been  under  observation  six  months.  On  opening 
the  abdomen  I  found  a  subperitoneal  myoma  attached  to  the  anterior  surface 
of  the  uterus.  It  had  received  the  greater  part  of  its  blood-supply  from  the 
omentum.  After  the  omental  vessels  had  been  tied  off  the  uterus,  which  con- 
tained several  myomata,  was  amputated  through  the  cervix.  The  ])atient  made 
an  uninterrupted  recovery. 

Path.  No.  7925.  The  specimen  consists  of  a  myomatous  uterus  with  a 
pedunculated  myoma  attached  to  its  anterior  wall.  The  uterus  is  enlarged, 
measuring  7.5  x  7  x  5  cm.  Its  outer  siu'face  is  smooth.  At  the  fundus  is  a  sub- 
peritoneal nodule,  6  nun.  in  diameter,  and  another  on  the  posterior  wall,  2.7 
X  2  cm.  Projecting  from  the  anterior  wall  and  attached  by  a  delicate  pedicle 
is  a  large  myoma.  Attached  to  the  upper  surface  of  this,  over  a  wide  area,  is 
omentum.  In  places  this  is  perfectly  normal ;  in  other  places  it  shows  marked 
diminution  in  the  amount  of  fat,  and  at  numerous  points  the  omental  vessels, 
now  al)solutely  devoid  of  fat,  are  seen  plunging  into  the  tumor  (Fig.  20).  This 
is  one  of  the  most  interesting  specimens  that  we  have  ever  seen,  as  it  clearly 
shows  the  various  stages  of  atrophy  of  the  omental  fat  when  the  omentum 
furnishes  a  parasitic  myoma  with  nourishment. 

Case  C.  (Hagerstown,  Md.). 

A  large  parasitic  m  }'  o  m  a  ^\■  i  t  h  m  a  r  k  e  d  develop  m  e  n  t 
of  the  omental  ^'  e  s  s  e  1  s ,  some  reaching  1  cm.  in  diame- 
ter  (Fig.  21).* 

C,  colored.  Seen  in  consultation  with  Dr.  Scheller  at  the  Washington 
County  Hospital,  Hagerstown,  on  August  4,  1906.  The  ])atient  had  had  an  ab- 
dominal tumor  for  five  years.  The  tumor  rose  al)ruptly,  and  projected  fully 
18  inches  from  the  general  abdominal  contour.  The  vagina  posteriorly  was 
greatly  encroached  upon. 

Operation.  On  opening  the  abdomen  the  tumor  encountered  was  every- 
where adherent  to  the  anterior  abdominal  wall  and  also  laterally.     Running  into 

*  Thomas  S.  CuUen,  A  Series  of  Interesting CJynccologic  and  ()l)stetric  Cases,  Jour.  Ainer. 
Med.  Assoc.,  May  4,  1907. 


PARASITIC    UTERIXK    .MYOMATA. 


25 


the  anterior  surface  of  the  tumor  from  its  upper  end  were  blood-vessels,  some  of 
them  nearly  1  cm.  in  diameter.     They  were  spread  out  over  an  area  16  cm.  in 


■"■-•;  —  --'"^ 


FlO.    20. — 'rUK    (IhADI  AI.    OlSAIM'KAHANCK    OF    OmKNTAI,    I'AT    WhKN    THK     OmKNITM    SkNDS    MaNY    \' KSSKl.S    TO    A 

Parasitic  Myoma.  (Nat.  size.) 
Path.  No.  792.").  The  uteru.-i  is  about  twice  the  iiiitural  size  and  cotitaiii.s  several  iiiyoiiiala.  .Attached  to  its 
anterior  surface  l)y  a  short  slender  pedicle  is  a  sliKhfiy  lohulated  myoma,  and  attached  to  the  myoma  over  a  wide 
area  is  omentum.  .\t  a  the  omental  fat  still  i)resents  the  usual  appearance.  .\t  b  there  is  atrojjh.v  of  the  fat  and 
the  vessels  stand  out  clearly.  At  c  there  is  still  further  atro])hy  of  the  omentum,  as  only  immediatel.v  around  the 
ves.sels  does  the  fat  still  persist.  At  d  all  semblance  of  fat  has  disap|>eared  and  we  see  the  omental  vessels 
spreading  out  over  the  surface  of  the  tumor  m-  pluiiuinn  dircctl\-  inlu  the  depths. 


breadth.     Passing:;  down  the  ritilit  side  of  the  tumor,  and  lyiiiii;  beneath  it,  was  a 
regular  rope  of  blood-vessels  (  Fii^.  21,  b').     These  lay  perfectly  fi'ee  from  the  sur- 


P'iG.  21.— A  Larce  Parasitic  Myoma  with  Huge  Vessels  Comint;  from  the  Omentum  (i  nat.  size.) 
The  tumor  weigher!  18  pounds,  and  wa.s  attached  to  the  uterus  by  a  pedicle.  5mm.x3cm.  .\t  the  top  is  a  broad, 
omental  adhe.sion  carrying  ves.sels  to  the  tumor.  At  b'  i.s  a  cros.s-section  of  a  portion  of  the  "  rope  of  omental  vessels, " 
which  passed  down  beneath  the  tumor  to  b,  and  then  turned  upward  again,  plunging  into  the  tumor,  a  rep- 
resents one  of  the  largest  blood-ve.s.sels,  which  stand  out  prominently.  Crossing  these  large  vessels  are  numerous 
adhesions,  c  is  a  portion  of  a  vessel  which  passed  down,  perfectly  free  from  the  omentum,  to  the  under  surface 
of  the  tumor. 

26 


PARASITIC    rT?:KIXE    MYOMATA.  27 

rounding  .structure.^,  could  be  liftt'd  up,  were  covered  with  peritoneum,  and  were 
evidently  omental,  but  no  fat  was  present.  These  vessels  formed  a  mass  6  cm. 
in  diameter,  and  looked  and  felt  like  small  snakes.  They  could  be  traced  down 
to  the  lower  end  of  the  tumor,  where  they  spread  out  over  its  surface  and  jjlunged 
into  its  substance.  One  of  the  vessels,  5  mm.  in  diameter,  passed  down  by  itself 
and  lay  absolutely  free  (Fig.  21,  c).  It  was  isolated  for  a  distance  of  18  cm., 
being  devoid  of  any  attachment  whatsoever.  It  had  originated  in  the  omentum, 
extended  downward,  and  plunged  into  the  tumor. 

After  liberating  the  vascular  supply  I  found  that  the  tumor  was  attached  to 
a  small  myomatous  uterus.  The  pedicle  was  3  cm.  in  breadth,  o  mm.  in  thick- 
ness, and  contained  only  one  blood-vessel  of  any  size.  The  pedicle  was  cut  and 
the  tmiior  delivered.  Of  the  vessels  passing  from  the  omentum,  as  a  rule  there 
was  one  artery  to  two  veins.     The  artery  was  about  one-third  the  size  of  the  vein. 

As  the  patient's  condition  became  rather  serious,  although  she  had  not  lost 
more  than  two  ounces  of  blood,  we  stopped  the  operation,  leaving  the  myomat- 
ous uterus  and  a  second  myoma,  fully  25  cm.  across.  This  also  had  vessels 
from  the  ouKnitum  plunging  into  its  uj^per  part,  and  was  attached  to  the  uterus 
by  a  pedicle  2  cm.  in  diameter. 

The  patie^nt  promised  to  return  to  the  hospital  for  removal  of  the  uterus  as 
soon  as  she  was  in  good  condition.  She  kept  putting  it  off,  however,  until 
finally,  at  the  end  of  onc^  and  one-half  years,  she  entered  the  hospital  with  the 
abdomen  as  distended  as  when  first  seen.  The  abdominal  scar  had  given  way, 
and  purulent  fluid  was  escaping  from  the  abdominal  cavity.  There  was  marked 
sepsis,  and  hysterectomy  was  out  of  the  cjuestion.  She  got  somewhat  better, 
but  died  after  a  few  months. 

The  hardened  specimen  measured  23  cm.  in  length,  25  cm.  in  breadth,  and 
20  cm.  in  its  anteroposterior  chameter.  It  was  markedly  nodular,  very  hard, 
and  weighed  IS  pounds.  ]']ven  in  the  hardened  s])e('imen  some  of  the  blood- 
vessels were  nearlv  1  cm.  in  diameter. 


Gyn.  No.  5784. 

A  V  e  r  y  1  a  )•  g  e  m  y  o  m  a  t  o  u  s  u  t  e  r  u  s  .  w  i  t  h  1  a  r  g  e  c  o  n  - 
g  e  r  i  e  s  of  o  m  e  11  t  a  1  a'  c  s  s  c  1  s  c  o  \'  c  r  i  11  g  its  s  u  i'  I'  ace:  d  c  n  s  e 
adhesions  to  the  b  I  m  d  d  c  i'  and  numerous  ^•  e  s  s  e  1  s  from 
t  h  e  b  1  a  il  d  e  r  s  u  p  p  1  y  i  n  g  11  o  u  r  i  s  h  111  cut  to  t  h  c  t  u  m  o  r 
(Fig.  22). 

.\.  Jv.,  coloi-ed,  aged  foi'ty-li\c,  iiiari'icd.  Admilted  .January  11:  discliai'ged 
Februai'v  1'.),  1S9S.  The  menses  wei'e  regular  until  a  yeai' ago.  Since  then  they 
have  been  diminishing  in  amount,  and  ha\'e  occuri'ed  at  longer  inter\-als.  ( )n 
vaginal  examination  the  cerN'ix  is  found  to  be  small,  pressed  down  by  a  hard 
pelvic  mass,  e^■idently  connected  with  a  large  tunioi-,  which  almost  completely 
fills  the  entii'c  abdomen,  extending  upward  to  within  two  inches  of  the  ej)igastri(' 


28 


-MYOMATA    OF    THK    ITKRUS. 


notch.     The  luiiior  is  firm,  hard  and  iinniobilc,  and  tender  only  over  the  sym- 
physis. 

Ojx'ration,  January  15,  189S.  Hysteromyomectomy;  right  oophorectomy. 
On  making  the  incision  I  found  a  hirge  tumor  filhng  the  entire  abdomen.  The 
uterus  had  rotated  180°  from  right  to  left.  Attached  to  the  entire  anterior  sur- 
face of  the  tumor  was  the  omentum,  which  sent  in  numerous  vessels  (Fig.  22). 
There  were  also  extensive  adhesions  to  the  bladder.     These  contained  large 


Fig.  22. — Large  Coxgkries  of  Omental  Vessels  Supplying  Nourishment  to  a  Myomatous  I'terus;  also 
N'essels  Passing  up  from  the  Bladder  to  the  Tumor. 
Gyn.  No.  5784.  This  picture  demonstrates  one  of  the  difficult  hysterectomies  that  frequently  confront  the 
surgeon.  In  such  a  case  the  incision  should  be  continued  upward  until  free  omentum  is  encountered,  and  then 
the  vessels  should  be  tied  twice  on  the  proximal  or  colon  side  and  once  on  the  distal  side.  It  is  better  not  to  use 
artery  forceps,  as  the  vessels  are  so  friable.  In  such  cases  the  ureters  are  often  drawn  up  in  festoon  fashion  along 
the  sides  of  the  tumor  by  adhesions,  and  may  readily  be  tied  accidentally  or  cut  if  extreme  care  is  not  exercised. 
(After  Howard  A.  Kelly.) 

vessels.  The  uterus  was  amputated  through  the  cervix.  Convalescence  was 
interrupted  by  a  mild  attack  of  salivation  after  taking  calomel.  Her  highest 
postoiK'i'ative  temperature  was  100.8°.     She  maile  a  satisfactory  recovery. 


Fig.  23. — X  Large  Myoma  E.ntirely  Separated  from  the  Uterus  and  Lying  Free  in  the  Omentu.m. 
Gyn.  No.  14709.  Path.  No.  12618.  On  opening  the  abdomen  the  large  myoma,  seen  in  the  upper  part  of  the 
picture,  presented.  It  measured  10  x  13  x  17  cm.,  and  had  large  numbers  of  omental  vessels  coursing  over  its 
surface.  The  omental  fat  had  here  to  a  great  extent  disappeared,  allowing  the  blood-vessels  to  stand  out  sharply. 
To  the  right  is  a  long  adhesion,  to  the  lower  end  of  which  an  elongated  subperitoneal  cyst  is  attached.  Two  similar 
and  smaller  cysts  are  attached  to  the  lower  and  anterior  surface  of  the  tumor.  .Ml  of  them  are  in  reality  small 
subperitoneal  cysts,  similar  to  those  so  frequently  associated  with  pelvic  adhesions.  Protruding  from  the  ab- 
dominal incision  is  a  small  myomatous  uterus.  Partially  enveloping  the  uterus  and  the  right  tube  and  ovary  is 
the  omentum,  which  is  continued  upward  and  envelops  the  myoma.  The  large  myoma  has  entirely  lost  its  connec- 
tion with  the  uterus. 


Ll 


Tig.  2:?. 

29 


30  MVOMATA    OF    THK    UTERI'S. 

Gyn.  No.  14709.     Path.  No.  12618. 

A   myoma    lying   free   in    the   omentum    (Fig.  23). 

One  of  the  most  interesting  examples  of  a  jxii-asitic  myoma  that  we  have  ever 
encountered  was  furnished  by  Case  147(M).  The  uterus  contained  several  small 
myoniata.  while  lying  enveloped  in  omentum  was  a  large  myoma  which  had 
entirely  lost  its  connection  with  the  uterus. 

Gyn.  No.  14709.  A.  C,  colored,  aged  thirty-seven.  Admitted  A])ril  0;  dis- 
charged May  2,  1908.  On  opening  the  al)d(jmen  one  of  us  (Cullen)  found  a 
large  mvoma  pi-esenting.  On  drawing  this  out  he  found  it  envelo])ed  in  omen- 
tum and  entirely  separated  from  the  uterus  (Fig.  23).  The  tumor  was  removed 
with  th(!  utmost  care,  the  large  omental  vessels  being  doubly  tied  and  cut. 
The  small  and  densely  adherent  myomatous  uterus  was  then   removed. 

Path.  No.  12618.  The  uterus  measures  2x5.5x7  cm.  and  contains  several 
small  myomata.  The  large  parasitic  myoma  measures  10x13x17  cm.  Its 
surface  is  uneven  and  nodulai'.  It  is  tii-m  in  consistency  and  covered  over  with 
omentum.  The  central  jwrtion  of  the  myoma  has  undergone  hyaline  degenera- 
tion, with  some  li([Uefaction,  and  there  is  extravasation  of  blood. 

Ascitic  Fluid  Accompanying  Uterine  Myomata. 

Ascitic  fluid  is  fre(|iiently  associated  with  fibroma  of  the  ovary,  but  only 
rarely  is  there  any  appreciable  amount  of  free  serous  fluid  accompanying  uterine 
myomata.  In  seven  of  our  cases  a  considerable  amount  of  ascitic  fluid  was 
detected  at  operation.* 

In  Gyn.  No.  978(),  in  which  the  rounded  myomatous  tumor  reached  to  within 
5  cm.  of  the  umbilicus,  the  abdomen  contained  200  c.c.  of  fr(>e  fluid.  A  glance 
at  the  history  will  show,  however,  that  other  factors  were  in  all  probability  re- 
sponsible for  the  ascites.  The  patient  had  a  loud  a})ical  systolic  murmur.  There 
was  marked  edema  of  the  feet  and  ankles,  and  the  hemoglobin  on  admission  was 
only  20  per  cent.,  but  reached  43  per  cent,  just  before  the  operation. 

In  Case  6272  the  uterus  contained  several  subperitoneal  myomata  and  was 
densely  adherent.  About  three  months  before  operation  1550  c.c.  of  fluid  had 
been  asj)irated  from  one  ])lem-al  cavity.  About  eleven  days  prior  to  the  opera- 
tion 8050  c.c.  of  ascitic  fluid  had  been  withdrawn  from  the  abdomen.  In  this 
case  the  cardiac  lesion  and  the  accompanying  nephritis  were  probably  respon- 
sible for  the  accumulation  of  fluid. 

The  free  fluid  in  the  abdomen  in  Cases  641S,  3387,  1383^,  12155,  and  P., 
C.  H.  I.  was  undoubtedly  caused  by  the  presence  of  the  tumor  and  not  by  any 
constitutional  impaii'inent . 

In  Case  12155  a  large  jK-dunculated  myoma  had  made  a  three-(|uarter  turn 
on  itself,  and  the  omentum  was  adherent  over  an  area  14  cm.  in  extent.     Some 

*  In  Cases  12166,  1218.5,  12678,  12871,  a  small  ainoimt  of  ascitic  fluid  was  also  found.  In 
Case  12)^48,  as  a  result  of  a  mild  )>critonitis,  tlie  abdomen  containetl  a  small  amount  of  free 
turbid  fluid  with  flakes  of  fibrin. 


PARASITIC    ITHHIXK    MYOMATA.  31 

of  its  vessels  entering  the  tunioi'  were  only  1  mm.  in  diameter.  The  alxlomen 
in  this  case  contained  two  ounces  of  clear  yellow  serum.  For  a  full  description 
of  the  case  see  p.  200. 

In  Case  6418  the  subperitoneal  pedunculated  myoma  weighed  29  pounds 
and  the  abdomen  contained  about  500  c.c.    of  ascitic  fhiid. 

In  Case  3387,  in  which  a  partially  parasitic  myoma  existed  (Fig.  24,  p.  34), 
marked  ascites  was  present,  7000  c.c.  of  free  fluid  being  found. 

In  Gyn.  No.  1383^  the  omentum  was  densely  adherent  to  the  tumor,  and  the 
abdomen  contained  14,500  c.c.  of  straw-colored  fluid,  and  about  2000  c.c.  of  a 
clear,  jelly-like  material,  that  was  scooped  out  with  thc^  hand.  The  urine  con- 
tained albumin,  but  no  casts.  After  removal  of  the  tumor  the  albumin  dis- 
appeared. 

Undoubtedly  one  of  the  most  remarkable  cases  of  the  intimate  association  of 
uterine  myomata  and  extensive  ascites  is  furnished  by  case  P.  In  this  case 
(p.  35)  the  subperitoneal  myoma  had  been  almost  completely  weaned  away 
from  the  uterus,  and  was  receiving  its  chief  blood-supply  from  the  posterior 
surface  of  the  bladder  and  from  huge  omental  vessels  (Fig.  25).  The  abdomen 
contained  51,000  c.c.  of  clear  ascitic  fluid. 

Cause  of  the  Ascites. — The  fluid  is  clear,  straw-colored,  and  usually  limpid, 
but  may  coagulate,  forming  a  loose,  clear,  jelly-like  mass. 

As  previously  mentioned,  fibromata  of  the  ovary  are  usually  accompanied 
by  ascites.  In  these  cases  the  large  vessels  in  the  loose  ])e(licle  are  undoubtedly 
twisted,  causing  a  transudation  of  serum.  That  the  fibroma  is  undoubtedly 
responsible  for  the  fluid  is  clearly  proved  l:)y  the  total  absence  of  free  abdominal 
fluid  after  removal  of  the  tumor. 

In  four  of  our  cases  the  condition  has  been  an  analogous  one.  The  myomata 
have  been  ])edunculated,  and  have  received  a  large  part  of  their  blood-supply 
from  the  omentum.  Partial  rotation  of  the  tumor,  with  twisting  of  the 
vessels,  had  from  time  to  time  undoubtedly  occurred,  and  transudation  of  serum 
into  the  abdomen  was  the  natural  I'esult.  A  I'eference  to  h'ig.  25  will  show  the 
slender  attachment  of  the  pedunculated  myoma,  and  any  latei'al  niovemeiit  of 
the  patient  was  undoubtedly  accompanied  by  a  partial  twisting  of  the  tumoi", 
shutting  off  the  blood-su))ply  of  the  huge  omental  Ncssels  and  favoring  the 
])ouring  out  of  serum.  It  is  now  four  and  one-half  years  since  the  tumor  was 
removed,  and  although  the  abdomen,  prior  to  operation,  contained  51  liters  ot 
fluid,  there  has  never  been  any  retui'ii  of  the  ascites. 

Cases  in  which  the  Myomata  were  Accompanied  by  Ascites,  in  the  following 
cases  the  i-eader  can  detei'inine  for  himself  the  probable  cause  ol  the  tree 
abdominal  fluid: 

Gyn.  No.  9786. 

Ascitic    fluid    associated    with    a    m  y  o  m  a  tons    u  t  e  r  >i  s  . 
M.  B.,  colored,  agi'd  forty.     Admittetl  .bily   15:    disch;ii-ged   Septembei-  20, 


32  MYOMATA    OF    THK    ITERUS. 

1902.  The  jwticnt  coiiiplains  of  the  jji'csciicc  of  an  abdominal  tumor  and  of 
general  weakness.  For  the  last  two  years  sh(>  has  suffered  from  weakness,  and 
has  had  numerous  fahitino;  sjh'IIs.  shortness  of  breath,  and  swellino;  of  the  feet. 
Her  weakness  she  attributes  to  a  profuse  menstrual  flow.  The  tumor  was  first 
noticed  af)out  a  >'ear  aii'o.  M  this  time  it  was  the  size  of  a  baseball.  The 
j)atient  is  exeeedingly  anemic,  and  shows  })uffiness  around  the  eyes,  a  loud  sys- 
tolic mui'imu',  marked  edema  of  the  feet  and  ankles,  and  a  hemoglobin  of  30 
pel-  cent. 

She  was  at  once  ])ut  to  l)ed,  given  iron  and  strychnin,  and  kept  as  much  as 
possible  in  the  open  air.  She  im])roved  rapidly.  On  August  14th  she  had  her 
usual  ])eriod,  which  was  profuse.  At  this  time  the  edema  of  the  ankles  and 
])uffiness  of  the  eyes  had  entirely  disa])peai'ed.  Her  hemoglobin  I'eached  43 
per  cent. 

Operation,  hysteromyomectomy,  August  26,  1902.  When  the  abdomen  was 
opened,  about  200  c.c.  of  free  fluid  were  foimd  and  a  rounded  soft  tumor  about 
the  size  of  a  fetal  head.  Hysteromyomectomy  was  done,  and  the  patient  made 
a  satisfactory  recovery.  At  the  time  of  her  discharge,  on  September  20,  1902, 
her  hemoglobin  had  reached  52  per  cent.  She  had  recovered  almost  entirely 
from  her  weakness  and  had  no  further  symptoms. 

The  ascitic  fluid  in  this  case  was  apparently  due  directly  to  the  general 
weakened  condition  and  to  the  low  hemoglobin.  Of  course,  indirectly,  the 
weakness  had  been  pi'oduced  to  a  great  extent  by  the  continued  loss  of  blood 
occasioned  In'  tiie  myoma. 

Gyn.  No.  6272.     Path.  No.  2530. 

Ascitic  fluid  associated  wit  h  u  t  e  r  i  n  e  m  y  o  m  a  t  a  . 
C  h  r  o  n  i  c   nephritis;   in  i  t  r  a  1   i  n  s  u  fh  c  i  e  n  c  y. 

B.  S.,  colored,  aged  thirty-six,  single.  Admitted  July  27;  discharged  August 
2S,  189S.  This  patient  was  admitted  to  the  gynecologic  department  from  the 
medical  service  on  July  27th.  In  A))ril  loot)  c.c.  had  been  withdrawn  from  the 
pleural  cavity,  and  on  July  16th,  8050  c.c.  of  ascitic  fluid  from  the  abdomen. 
The  patient's  last  menstrual  period  had  occurred  in  November,  1897.  On 
admission  to  the  gynecologic  service  a  diagnosis  of  uterine  myomata,  chronic 
ne])hritis,  and  mitral  insufhciency  was  made. 

Operation,  July  27,  1S9S.  Hysteromyomectomy  with  I'emoval  of  the  ai)})en- 
dages.  The  posterior  surface  of  the  uterus  was  densely  adherent  to  the  l)i'oad 
ligament  and  pelvic  floor,  and  both  tubes  and  ovaries  were  buried  in  adhesions. 
The  bladder  on  the  left  sitle  was  adherent  to  the  uterus,  and  there  was  a  con- 
siderable amount  of  cystic  pelvic  peritonitis  in  t  he  cul-de-sac.  The  apjiendix  was 
adherent  to  the  right  ovary,  lying  under  the  tumor.  The  highest  postoj^erative 
temi)erature  was  103.2°.     The  ])atient  made  a  .satisfactory  recovery. 

Path.  No.  2530.  The  specimen  consists  of  the  enlarged  uterus,  with 
the  tubes  and  ovaries   intact.     The   uterus  is  aj)j)r()ximately  18x14x15  cm. 


PARASITIC    I'TERIXK    MVO.MATA.  33 

The  increase  in  size  is  due  to  tlie  })i'esence  of  sul)|)eritoneal  interstitial  and  sub- 
niucous  myomata.  Coverinii  the  anterior  and  posterior  surfaces  are  numerous 
adhesions.  The  uterine  cavity  is  6  cm.  in  length  and  its  mucosa  is  much  atro- 
phied. The  chief  interest  in  this  specimen  is  centered  in  the  subperitoneal 
myoma,  7  cm.  in  diameter.  This,  on  section,  presents  the  usual  myomatous 
appearance,  save  over  an  area  measuring  3.5x2.5  cm.  Here  large,  irregular, 
cyst-like  spaces  are  present,  the  walls  of  which  are  very  delicate.  Extending 
across  them  are  fine  tral^'cuhp.  Clinging  to  the  walls,  and  ])artly  filling  the 
cavity,  are  quantities  of  l)lood.     The  appendages  are  covered  with  adhesions. 

Histologic  Examination. — The  walls  of  the  cyst-like  spaces  are  composed  of 
hyaline  myomatous  tissue,  totally  devoid  of  nuclei.  The  inner  surface  of  the 
cysts  have  no  lining.  They  are  covered  with  blood.  These  cyst-like  spaces, 
therefore,  are  nothing  more  than  areas  in  which  the  hyaline  myomatous  tissue 
has  undergone  liquefaction,  followed  by  hemorrhage. 

In  this  case  the  myoma  may  have  had  a  causal  relation  to  the  develo})ment 
of  ascitic  fluid,  but  the  nephritis  and  the  mitral  insufficiency  were  undoubtedly 
directly  responsible  for  the  pouring  out  of  the  fluid  into  the  abdominal  and 
pleural  cavities. 

Gyn.  No.  6418. 

Ascitic    fl  u  i  d    associated    with    a    uterine    m  y  o  m  a  . 

M.  W.,  colored,  aged  thirty-nine,  married.  Admitted  October  9;  discharged 
November  7, 1898.  The  patient  has  never  been  pregnant.  Her  menses  began  at 
seventeen,  were  regular,  lasting  five  or  six  days,  and  associated  with  considerable 
pain  until  the  last  three  or  four  months.  The  tumor  was  noticed  three  years 
ago.  Latterly  she  has  had  shortness  of  breath.  The  abdomen  is  greatly  and 
irregularly  distended. 

Operation,  October  12,  1S9S.  Hysteromyomectomy.  The  large  dense  mass 
was  liberated  and  brought  out.  It  was  attached  to  the  uterus  by  a  pedicle  2  cm. 
broad.  As  the  tumor  was  draw  out,  aljout  500  c.c.  of  ascitic  fluid  escaped.  The 
tumor  was  liberated  from  left  to  right  in  the  usual  way.  It  weighed  29  pounds. 
The  free  oozing  in  the  pelvic  floor  was  checked  with  numerous  sutures.  The 
right  ureter  was  about  twice  the  natural  size.  The  highest  postoperative  tem- 
perature was  100.2°.     The  patient  made  a  satisfactory  recovery. 

In  this  case  the  myoma  seems  to  have  been  the  cause  of  the  ascitic  fhiid. 

Gyn.  No.  3387.     Path.  No.  641. 

Ascitic  fl  u  i  d  a  s  s  o  c  i  a  t  e  (I  with  a  large  111  y  o  111  a  I  o  u  s 
uterus.  One  ]>  e  d  u  n  c  u  1  a  1  e  (1  in  y  o  ni  a  i' e  c  e  i  v  e  d  p^rl  ol  its 
n  o  u  r  i  s  h  m  e  n  t    f  r  o  m    the   o  111  e  n  I  u  in  ( l-'ig.  21). 

M.  S.,  white,  aged  thirt>-t\vo,  mnn-ied.  .\(lmitte(l  Maivli  20:  discharged 
April  27,  1S95.  The  patient  has  been  ninrrieil  Iwelve  yeai's  and  has  had  two 
children;  no  miscarriages.  The  menses  wei-e  i-egulai'  until  an  attack  of  typhoid 
3 


34 


MYOMATA    OF    THE    UTERUS. 


fever,  one  year  ag(3.     Since  then  they  have  been  somewhat  irre<i;iihir  and  the 
flow  is  free. 

Soon  after  the  birth  of  the  youn<iest  child,  live  years  ago,  she  noticed  a  lump 
the  size  of  a  hen's  egg  in  the  midline  of  th(>  lower  abdomen.  About  eighteen 
months  ago  her  abdomen  began  to  increase  in  size,  and  has  been  gradually  en- 
larging up  to  the  present  time.  When  she  turns,  the  mass  seems  to  move  from 
side  to  sitle,  and  then^  is  pres(mt  a  constant  dragging  sensation,  with  occasional 
sharp  })ains,  especially  on  the  right  side. 

The  abdomen  is  distended  by  several  distinctly  palpable  tumors.     Some  of 

these  give  a  definite  ballottement 
and  there  is  marked  distention  of 
the  abdomen  with  ascitic  fluid.  The 
ballottement  is  easily  obtainable 
with  two  large  masses.  The  cervix 
is  jannned  down  to  the  pelvic  floor 
by  the  tumor.  The  urine  is  normal. 
Operation,  March  23,  1895.  Hys- 
teromyomectomy.  After  the  inci- 
sion, 7  liters  of  ascitic  fluid  were 
evacuated.  One  of  the  large  pe- 
dunculated nodules  had  four  large 
omental  vessels  entering  it  (Fig.  24) . 
These  were  tied  and  separated.  The 
highest  postoperative  temperature 
was  100.3°  on  the  second  day. 

Path.    No.     641.      The    uterus 
measures  14  x  17  cm.     It  is  smooth 
^     „      ^  ,,  ^  „  and  glistening.     Springing  from  its 

Fig.  24. — Omental  Vessels  Supplying  a  Subperitoneal  _  o  i         <-t      l 

Pedunculated  Myoma,  and  Associated  with  7000        autcrior  SUrfaCe  is  a  globular  Uodule, 
CO.  OF  Ascitic  Fluid.  n         n        o  Tj-    •         4-^       U      i    i 

^     ^,  .    ,  .,  ,  9x9x8  cm.     It  is  attached  by  a 

Gyn.  No.  .3387.     Path.  No.  041.     The  uterus  measured  ...  . 

14x17  cm.     .\ttached  to  the  fundus  are  two  pedunculated         ])edicle    1.5    CUl.    ill    length,    3    ClU.    in 
invomata,  one  of  which  has  several  omental  vessels  entering         i  i.i         ^^       •        ■         v  ii       r  i 

it."    On  palpation  one  of  the  vessels  gave  a  definite  bailotte-         Ijl-^'^dth.      Springing  irolll  the  fuuduS 
nient.     The  abdomen  contained  7000  c.c.  of  clear  fluid.  ^g   another    IX'duilCulatC^d    Uodule    ir- 

regularly oval,  and  measuring  10  x  8 
x  6  cm.  The  entire  left  lateral  wall  of  the  uterus  is  occupied  by  a  tumor 
10  X  7.5  X  6  cm.  It  is  oval  in  shape,  regular  in  outline^,  and  has  a  secondary 
nodule,  2  x  2  x  2.1  cm.,  springing  fi'om  its  imder  surface.  The  uterus,  on  sec- 
tion, is  found  to  contain  numerous  interstitial  and  some  submucous  nodules. 
The  uterine  muco.sa  is  smooth  and  glistening,  and  apparently  much  atrophied. 
The  tubes  and  ovaries  on  both  sides  are  normal. 

Histologic  Examination. — The  uterine  mucosa  is  atrophic,  but  otherwise 
normal.  All  the  tumors  consist  of  fibers,  most  of  which  are  cut  transversely. 
The  tissue  is  rather  lax  and  shows  a  slight  amount  of  hyaline  degeneration. 


PARASITIC    UTERINE    MYOMATA.  35 

In  tlii.s  case  the  oiuciital  vessels  <i;i'()\viiig  into  the  sul)])entoneal  and  peduncu- 
lated niyonia  were  a})i)arently  the  source  of  the  ascitic  fluid. 

Gyn.  No.   1383^. 

A  1  a  r  g  e  q  u  a  n  t  i  t  y  of  ascitic  fl  u  i  d  a  s  s  o  c  i  a  t  e  d  with 
a  }3  a  r  t  i  a  1 1  y   p  a  r  a  s  i  t  i  c  u  t  e  r  i  n  e  ni  y  o  ni  a  . 

R.  G.,  colored,  aged  thirty-four,  married.  Admitted  May  12;  discharged 
July  5,  1892.  The  patient  has  been  married  eighteen  years,  but  has  never  been 
pregnant.  For  the  j^ast  two  years  she  has  had  pain  in  the  left  ovarian  region, 
steadily  growing  worse.  In  December,  1891,  her  abdomen  commenced  to  swell. 
About  two  years  ago  she  noticed  that  her  feet  and  ankles  were  edematous. 
The  abdomen  is  uniformly  distended.  The  urine  contains  albumin,  but  no 
casts. 

Operation,  May  16,  1892.  Hysteromyomectomy.  When  the  abdomen  was 
opened,  about  14,500  c.c.  of  clear  straw-colored  fluid  escaped,  and  later  about 
2000  c.c.  of  clear,  jelly-like  material  were  removed  with  the  hand.  The  myomat- 
ous uterus  rose  from  the  pelvis  and  extended  about  8  cm.  above  the  umbilicus. 
The  omentum  was  intimately  adherent  to  the  upper  and  anterior  s\u-face  of  the 
tumor.  Hysterectomy  was  performed.  The  temperature  gradually  rose  to 
102°  by  the  tenth  day,  and  then  fell  to  normal.  It  again  reached  102.6°  by 
the  twenty-seventh  day,  when  there  w^as  some  pulmonic  dulness.  The  albumin 
disappeared  entirely  after  operation.  The  patient  left  the  hospital  on  July 
8th,  but  she  still  had  some  fever. 

P.   C.  H.  I.* 

A  p  a  r  t  i  a  1 1  y  p  a  r  a  s  i  t  i  c  myoma,  a  s  s  o  c  i  a  t  e  d  ^^•  i  t  li  51 
liters    of    ascitic    fluid   (Fig.  25). 

P.,  aged  fifty-four,  white,  single.  Admitted  October  29,  1902,  complaining 
of  marked  abdominal  enlargement.  Her  face  was  drawn  and  pinched.  She 
was  exceedingly  thin;  the  al)domen  was  tremendously  and  uniformly  distended. 
From  the  ])ubes  to  the  sternum  in  the  midline  there  was  dulness.  and  on  ]u'rcus- 
sion  a  very  distinct  wave  of  fluctuation  was  easily  detected. 

A  diagnosis  of  ovarian  cyst  was  made,  and  after  a  delay  of  a  few  days  on 
account  of  a  slight  bronchitis,  the  abdomen  was  opened.  The  peiiloneum 
was  much  thickened.  The  great  distention  was  due  to  ascitic  lluid,  ")l  liters  being 
removed.  Attached  to  the  fundus  by  a  \-ery  small  ju'dicle  was  a  myomatous 
nodule  16  cm.  long  (Fig.  25).  Plunging  into  llie  upper  or  free  surface  of  this 
nodule,  were  numerous  blood-vessels,  each  about  ;^  (ir  I  iimi.  in  diameter,  torluous, 
and  closely  resembling  angle-worms.  On  being  ti'aced  ujiward,  they  proved 
to  be  the  large  omental  vessels.  The  omentum  as  such  was  i-ecdgnized  as  a 
fringe,  not  more  than  5  mm.  long,  projecting  from  the  iowei-  edge  ol  the  tran.s- 

*  Thomas  S.  Culicii,  .J.  A.  .M.  \..  XovcihIkt  lit.  1<)()I,  p.  l.')l_'.  .\  Partially  I'arasitic  Uterine 
Myoma,  Associated  witli  .'>!   Liters  of  Aseitie  Fluid. 


36 


MYOMATA    OF   THK    ITHRIS. 


verse  eoloii.  The  altei'ed  omental  \-essels  were  exceediiitily  friable,  and  ruptured 
on  the  sliiihtest  manipulation.  The  pai'asitie  myoma  derived  part  of  its  hlood- 
su])j)ly  from  the  bladder,  to  which  it  had  become  inthnately  attached.  After 
tying  off  the  blood-supply  of  the  myonui  the  growth  was  easily  removed  and 
the  patient  made  a  satisfactory  recovery. 


Fig.  25. — A  Partially  Parasitic  Uterine  Myoma  Associated  with  51  Liters  of  Ascitic  Fluiu. 
.\ttached  to  the  fundu.s  by  a  narrow  pedicle  is  a  subperitoneal  myoma.  Plunging  into  the  edge  of  the  myoma 
are  the  omental  vessels.  The  omental  fat  has  almost  entirely  disappeared.  The  myoma  was  intimately  blended 
with  the  posterior  surface  of  the  bladder,  from  which  it  received  a  good  deal  of  nourishment.  The  abdomen  is 
markedly  distended  with  a,scitic  fluid.  The  small  intestines  were  effectually  held  back  by  the  tumor  and  the 
omental  vessels.     (After  Thomas  S.  Cullen.) 

March  1,  1007:  The  patient  is  at  the  present  time  in  good  health,  and  there 
has  never  been  any  return  of  the  ascitic  fluid. 

In  this  case  we  had  to  rely  entirely  on  the  j)hysical  signs,  as  the  patient  was  of 


Fig.  26. — A  Partially  Par.vsitic  Myoma,  Receiving  Part  of  its  Nourishment  from  the  Fallopi.^n  Tubes. 

(i  nat.  size.) 
C.  H.  I.  No.  4'Jo.  The  uteru.s  contains  several  interstitial  inyomata.  Attached  to  the  posterior  surface  of 
the  uterus  b.v  a  short  pedicle  is  a  l)road,  lobulated  myoma.  On  the  left  side  an  artery  and  vein  pass  from  the 
outer  end  of  the  tube  to  the  anterior  surface  of  the  tumor.  Tlie  branches  of  the  artery  sjireatl  out  over  the  tumor 
On  the  right  side  is  what  might  be  termed  an  unneces.sarily  long  adventitious  artery,  passing  from  the  outer  end 
of  the  tube  to  the  posterior  surface  of  the  tumor,  where  it  plunges  into  the  depth.  The  accompanying  vein  clings 
like  a  vine  to  the  artery,  taking  a  very  tortuous  course.  The  fimbriated  ends  of  both  tubes  are  patent.  The 
left  ovary  is  normal.  The  right  was  not  removed.  The  cy.stic  spaces  near  the  outer  ends  of  both  tubes  are 
probal)ly  dilated  lynipli-spaces.      There  is  no  evidence  of  pelvic  peritonitis. 


I'n;   26. 

37 


38  MYOMATA    OF    THK    ITKIUS. 

unsoiiiul  luiiul,  and  U])  to  the  day  of  operation  no  history  could  he  oljtaincd. 
The  facial  expression  and  the  al)d()ininal  signs  tallied  in  every  particular  with 
those  referable  to  an  ovarian  cyst,  and  without  the  clinical  history  a  correct 
diagnosis  was  impossible.  The  tyni])any  in  the  flanks  is,  on  first  thought, 
ditiicult  of  exjilanation,  but  when  we  i-eiueinber  that  this  myoma,  with  the  omental 
vessels  attached,  stretched  almost  the  entir(>  length  of  the  al)domen,  it  is  readily 
seen  that  the  small  intestines  were  held  l)ack  and  at  the  same  time  forced  out 
laterally.  I'nder  any  circumstances  there  would  have  been  dulness  over  the 
entire  antei'ior  abdomen,  as  the  intestines,  even  if  not  held  back  by  th(>  tumor 
and  omental  vessels,  could  not  have  reached  the  surface,  their  mesentery  not 
being  long  enough.  A\'e  know  of  no  instance  in  th(>  literature  in  which  such 
a  hirge  ([uaiitity  of  ascitic  fluid  was  ass(X'iated  with  a  myoma. 

A  Partially  Parasitic  Myoma,  Receiving  Part  of  its  Blood-supply 
FROM  the  Fallopian  Tubes. 

In  this  case  (Fig.  26)  the  uterus  was  slightly  enlarged  and  contained  several 
small  myomatous  nodules.  Projecting  from  the  posterior  surface  was  a  broad, 
lobulated  subperitoneal  myoma  attached  by  a  small  pedicle  (a).  Passing 
into  the  anterior  surface  of  the  myoma  was  a  small  artery  from  the  left  tube, 
and  into  the  posterior  surface  of  the  tumor  a  large  artery  from  the  right  tub(\ 
This  artery  was  very  long,  and  lay  perfectly  free  in  the  abdomen.  Coiled  around 
it  was  the  accompanying  vein.  There  were  no  omental  adhesions.  The  fimbri- 
ated ends  of  both  tul)es  were  normal,  hence  it  is  at  first  glance  difficult  to  explain 
how  the  tul)al  vessels  ever  reached  the  myoma.  AVhile  the  myoma  formed 
an  integral  part  of  the  uterus,  delicate  adhesions  evidently  formed  between  the 
outer  ends  of  the  tubes  and  the  myoma  and,  as  the  myoma  became  more  and 
more  pedunculated,  the  uterine  blood-supply  diminished  and  the  tubes  gradually 
sent  in  vessels  to  the  myoma  through  the  existing  adhesions. 

From  a  clinical  standpoint,  the  case  is  interesting  because  if  the  jK'dicle  had 
become  still  more  attenuated  and  had  been  finally  severed,  the  myoma  would  have 
been  entirely  supported  by  the  large  tubal  vessels;  then  any  sudden  jolting  might 
readily  have  caused  a  rupture  of  one  of  the  adventitious  vessels  and  a  fatal  hemor- 
rhage have  followed. 

C.  H.  I.    No.  495. 

L.  C.  B.,  aged  thirty-six,  married.  Seen  in  consultation  with  Dr.  P.  B. 
Norment,  and  admitted  March  12;  discharged  April  2,  1905.  The  patient  has 
never  been  pregnant.  For  the  past  month  there  has  been  dull  ])ain  down  the 
right  side  of  the  abdomen.  Otherwise  the  ])atient  feels  })erfectly  well,  and  it 
was  not  until  eight  days  ago  that  she  noticed  the  tumor. 

Operation.  March  l.'Jth,  hysteromyomectomy,  with  removal  of  the  uterus, 
both  tubes,  and  the  left  oN'aiy.  When  the  abdomen  was  opened,  a  most  unusual 
picture  was  seen  (Fig.  2()).  Several  greatly  twisted  l)lood-vessels  lay  perfectly 
free  on  the  surface  of  the  tumor  and  between  the  tubes  and  ovaries  on  both 


PARASITIC    ITKRIXK    MVO.MATA. 


39 


sides  were  cysts  with  very  thin  walls,  which  api)eared  to  be  dilated  lymphatics. 
The  uterus  was  renio\'ed  in  the  usual  way  from  left  to  right.  The  highest 
postoperative  temi)erature  was  100.4°  F. 


A  Parasitic  Myoma  Situated  at  the  Pelvic  Brim  Fig.  27  and  Receiving  its  Entire 

Blood-supply  from  the  Superior  Mesenteric  Vessels,  from  the 

Peritoneum,  and  from  Appendiceal  Adhesions. 

This  is  the  second  case  in  our  series  in  which  the  myoma  had  become  entirely 
separated  from  the  uterus.    (See  Fig.  23,  p.  29.)    It  lay  just  above  the  pelvic  brim, 


Fig.  27. — A  Parasitic  Myoma  in  no  way  ("eNNi;c-Ti;i)  with  the  Uterus. 
Gyn.  No.  9540.     This  myoma  was  attached  to  the  peritoneum  over  the  right  ureter  and  the  large  ve-^sels.     It 
had  received  the  greater  part  of  its  nourishment  from  vessels  which  appeared  to  be  derived  from  the  superior 
mesenteric  artery;    it  was  also  firmly  adherent  to  the  appenilix.     For  the  appearance  of  the  myomatous   uterus 
see  Fig.  28. 

and  great  care  had  to  be  exercised  during  its  removal  to  avoid  injury  to  the 
ureter  and  the  neighboring  vessels.  The  nourishment  appeared  to  lia\c  come 
from  the  arteries  supplying  the  small  bowel. 

In  this  case  the  uterus  was  about  three  times  the  natural  size  (Fig.  2S)  and 
contained  several  myomata.  All  the  appearances  at  operation  indicated  that 
the  myoma  had  originated  in  the  uterus  and  hml  latei-  engrafted  itself  on  to  the 
tissue  at  the  ])elvic  brim. 


40 


:my()Mata  of  thk  uterus. 


Gyn.  No.  9540. 
A'.  H..  coloivcl,  aged  f()i1y-()ii(\  Admitted  Ai)ril  7:  dischariicd  May  S.  1902. 
The  j)aticnt  complains  of  pain  in  the  abdomen  toward  the  end  of  the  menses, 
and  of  an  abdominal  tumor.  She  has  had  two  children,  the  youngest  twenty-two 
years  of  age.  fifteen  yc^ars  ago  she  first  began  to  have  dysmenorrhea  and 
cramps.  Two  years  ago  a  vaginal  section  was  done  for  a  douljle  pyosalpinx 
(Gyn.  No.  6226).  Further  operation  was  advised,  but  refused.  For  six  months 
the  ]iatient  was  free  from  pain,  but  after  that  the  pain  returned  and  during  the 
last  two  months  has  been  very  severe,  so  that  the  patient  has  been  confined  to 
bed  most  of  the  time.  For  three  weeks  she  has  had  difficulty  in  urination  and 
severe  bearing-down  pains  at  the  same  time. 


Fig.  28. — Mui.tixodular  Myomatous  Uteris  with  a  L?;ft  Prs-TCBr:.     {i  nat.  size.) 
Gyn.  No  9540.     The  specimen  is  of  interest  only  as  forming  the  key  to  Fig.  27.    One  of  the  myomatous  nodules 
had  evidently  become  completely  separated  from  the  uterus  and  engrafted  itself  on  to  the  peritoneum  just  above 
the  pelvic  brim. 


Ojx'ration.  Hy.steromyomectomy  and  appendectomy.  A\'hen  the  abdomen 
was  opened,  a  myoma  was  seen  lying  just  above  the  pelvic  brim,  absolutely  in- 
de{)endent  of  the  uterus,  and  attached  to  the  mesentery  at  the  inner  side  of  the 
cecum  (Fig.  27).  The  uterus  was  irregularly  nodular  (Fig.  28)  and  about  three 
times  its  natural  size.  It  was  amputated  through  the  cervix  and  removed.  The 
appendix  was  adherent  to  the  parasitic  myoma  and  was  also  removed.  The 
l)arasitic  myoma  had  obtained  most  of  its  blood-supply  from  the  superior 
mesenteric  ve.s.sels.  It  was  entirely  outside  the  pelvis  and  in  no  way  con- 
nected with  the  uterus.  The  jxitient  made  a  rather  tardy  recovery.  She  was 
extremely  constipated  and  had  vesical  irritability. 

On  histologic  examination  the  j)arasitic  myoma  showed  extensive  hyaline 
changes,  but  there  were  no  fui'thei-  evidences  of  necrosis. 


pakasitic  uterine  myo.mata.  41 

Adventitious  Intestinal  Vessels  Furnishing  Nourishment  to  Uterine  Myomata. 

Uterine  niyonuita,  whether  coniphctited  with  ]);ith()l()o;ic  lesions  in  the  a])peiRl- 
ages  or  not,  are  prone  to  develop  adhesions,  and  naturally,  where  adhesions  exist, 
the  intestines  may  be  implicated.  As  a  rule,  these  adhesions  consist  chiefly  of 
fibrous  tissue,  but  should  the  uterine  nourishment  to  the  myoma  diminish, 
arteries  will  occasionally  l)e  sent  from  the  intestines  to  the  tumor  along  the 
already  existing  adhesions. 

In  the  accompanying  grou})  we  mention  only  the  more  pronounced  cases. 

In  Case  6324  (Fig.  30)  a  large  pedunculated  myoma  si)rang  from  the  posterior 
surface  of  the  uterus  and  attached  to  over  half  of  the  anterior  surface  were  dense 
intestinal  adhesions  containing  many  blood-vessels.  The  intestines  furnished  a 
liberal  blood-supply  to  the  myoma. 

In  Case  9027  a  multinodular  myomatous  uterus  received  much  nourishment 
from  the  omental  vessels.  The  intestines  were  adherent  to  on(>  of  the  tumors. 
These  adhesions  consisted  almost  entirely  of  blood-vess(>ls.  The  main  tumor 
in  this  case  weighed  29  pounds. 

The  multinodular  myomatous  uterus  in  Case  6774  was  wedg(>d  in  the  pelvis 
by  adhesions.  The  sigmoid  flexure  was  densely  adherent  to  the  uterus  and 
furnished  the  tumor  with  large  adventitious  vessels. 

In  Case  7226  the  patient  was  in  a  precarious  conditicjn,  due  to  partial  intes- 
tinal obstiiiction  caused  by  the  adherent  multinodular  myomatous  uterus. 
One  of  the  pedunculated  myomata  was  becoming  strangulated,  through  torsion 
of  the  pedicle.  On  exposure  the  sigmoid  flexure  was  fomid  adherent  to  th(> 
tumor  and  sending  numerous  well-developed  vessels  to  the  myoma. 

In  Fig.  29  we  see  numerous  vessels  passing  from  th(>  rectum  to  the  myoma. 
The  right  tube  and  ovary  also  seem  to  furnish  their  (juota  of  blood  to  the  tumor. 

In  some  instances  the  relation  between  the  pedunculated  myoma  and  th<' 
intestine  becomes  very  close, and  if  the  myoma  undergoes  degeneration,  with 
cavity  formation,  an  opening  may  be  established  between  the  cavernous  myoma 
and  the  intestine.  Such  a  condition  existed  in  Case  9()7S  (Fig.  32).  The  pedun- 
culated myoma  had  received  ])art  of  its  nourishment  fi'om  tiie  omentum,  |>art 
from  the  uterus,  and  the  remainder  from  the  cecum.  A  direct  coininunicalion 
existed  between  the  interior  of  the  degenei-ated  myoma  and  the  lumen  of  the 
cecum. 

An  even  more  advanced  case,  somewhat  siniihir  in  character,  came  undei-  the 
care  of  Dr.  J.  Mason  Hundley,  of  the  Fniversity  of  Maryland.  The  patient  had 
been  luidei-  the  ob.^ervation  of  anolhei'  jjliysician  for  over  two  yeai's  and  a  diag- 
nosis of  uterine  myoma  had  l»een  made.  At  o|)eration  a  ulenis  practically 
normal  in  size  was  found.  It  containe(l  a  small  subperitoneal  myoma.  Filling 
the  pelvis  was  tlie  i)arasitic  cystic  myoma  seen  in  l''ig.  33.  It  had  i-eceived  its 
entire  nourishment  from  the  small  bowel,  and  had  a  broken-down  cavity  in  its 
center.     This  communicated  directlv  with  the  hmien  of  the  gut,  allowing  the 


42 


MYOMATA    OF   TlIK   ITKRUS. 


free  passage  of  fecal  matter  from  the  l)owel  into  the  ])arasitic  luxUde.     The  my- 
oma was  attached  to  the  uterus  by  a  few  slender  adhesions. 

Such  a  condition  is  exceedingly  rare,  and  yet  the  possibility  of  so  serious  a 
complication  should  not  be  overlooked. 


i,<Lj.  iCrr-^  _ 


Fit;   29. — .\  MvoM  V  Kkckivixg  Mich  of  its  Nourishment  from  the  Rf.ctum  and  .Apparently  from  the  Right 

Ov.\RY  .\ND  Tube.     (§  nat.  size.) 
C.  H.  I.  No.  18-14.     The  uterus  contained  several  m.vomata.     The  largest  is  posterior  to  the  uterus  and  was 
firmly  fixed  on  the  iielvic  floor.     From  the  fimbriated  end  of  the  right  tulie  and  from  the  inner  end  of  the  right 
ovary  many  vessels  pass  to  the  myoma.     Numerous  vessels  are  also  seen  e.xtending  from  the  rectum  to  the  tumor. 

Gyn.  No.  6324. 

A  large  sub  p  e  r  i  t  o  11  e  a  1  ])  e  d  u  n  c  u  1  a  t  e  d  m  y  o  m  a  ,  r  e  - 
c  e  i  V  i  n  g  m  u  c  h  of  it  s  n  o  u  r  i  s  h  m  e  n  t  f  r  o  m  the  intestines 
(Fig.  30). 

N.  R.,  colored,  aged  thirty-six,  married.  Admitte(l  August  26;  discharged 
October  1,  LSOS.  The  ])atient  has  had  an  abdominal  enlargement  for  the  past 
six  years.     She  lias  had  two  children,  but  no  miscarriages. 

Operation,  August  29,  1898.  Hysteromyomectomy.  An  incision  15  cm.  in 
length  was  made  through  thick  abdominal  walls  and  a  large  pedunculated  myo- 
ma found.     The  upper  portion  of  the  tumor  and  part  of  its  posterior  surface  were 


PARASITIC    UTERIXK    :\IYOMATA. 


4:^ 


donsoly  adherent  to  the  mtesthies.  The  large  timior  exteiRU  d  well  iij)  iiiuler  the 
costal  margin.  The  enucleation  was  begun  in  the  ])elvis,  by  tying  oft'  the  pedicle 
of  the  large  tumor  and  of  a  smaller  one  on  the  left  side.  The  tumor  was  next 
lifted  out  of  the  abdomen,  the  intestines  were  covered  with  warm  gauze,  and  the 
separation  of  the  tumor  and  intestines  was  effected.  The  intestinal  adhesions 
w^re  very  dense,  and  contained  numerous  quite  large  blood-vessels.  The  tumor 
had  evidently  received  a  considerable  part  of  its  blood-supply  from  the  adherent 
intestines.  The  raw  areas  were  brought  together  with  catgut  and  the  abdomen 
^^'as  closed.  The  highest  post- 
operative temperature  was 
101.4°  F.  The  patient  made 
a  satisfactory  recoverv. 


^c^ 


;Sifcs 


& 


Gyn.  No.  9027. 

A  m  u  1  t  i  n  o  d  u  1  a  r 
m  y  o  m  a  t  0  u  s  u  t  e  r  u  s 
receiving  part  of 
its  blood- sup  ply 
from  the  intestines. 

E.  S.,  colored,  aged  thirty- 
nine.  Admitted  August  30; 
discharged  October  5,  1901. 
The  patient  has  been  married 
twenty-two  years  and  has 
had  one  child.  For  ten  years 
she  has  thought  that  she  had 
an  abdominal  tumor,  but  this 
was  only  definitely  determined 
three  weeks  ago.  During  the 
last  year  it  has  grcnvn  con- 
siderably and  she  has  lost  a 
good  deal  in  weight.  At 
present  she  is  rather  pale,  l)ut 
fairly  well  nourished. 

Operation.  Hysteiomyo- 
mectomy.  When  the  aljd(jnien  was  opened,  a  multinodular  myoma  was  im- 
mediateh'  seen.  A  large  jjorlion  of  its  surface  was  cox-ci'cd  wilh  adherent 
omentum  and  many  of  llic  oiiicnlal  vessels  cntci'cd  directly  inio  ihc  tumor. 
instead  of  spreading  out  on  the  surface.  The  intestines  wci-e  adlieicnt  in  se^•eral 
places,  and  these  adhesions  consisted  niniost  entirely  of  blood-vessels.  After 
the  adhesions  had  been  separated,  the  uterus  was  i-enioxcd  without  dilliculty. 
It  weighed  29  pounds.     The  p.-ilieni   was  dischai'^'eil  in  good  condition. 


Fig.  30. — A  Large  Suhi'eritonk.\l  Peduncui-ated  .Myoma,  Re- 
ceiving Much  of  its  Nourishment  from  the  Intestines. 
Gyn.  No.  6324.  The  large  pedunculated  subperitoneal  nodule 
.shows  a  raw  area  over  its  upi)er  and  anterior  surface.  Here  it  waa 
completely  covered  by  intestinal  loojjs,  which  were  densely  adherent 
to  it.  The  intestines  had  sent  large  vessels  into  the  luinor,  as  is  seen 
by  the  cross-sections  of  arteries  and  veins  scattered  throughout  the 
roughened  raw  area. 


44  MY()^[ATA    OF    Till-:    UTERUS. 

Gyn.  No.  6774. 

A  m  y  o  111  a  tons  n  t  c  r  n  s  r  c  c  0  i  v  i  11  s;  a  large  adventitious 
vessel   fro  ni   the  s  i  tj;  ni  o  i  d  fl  c  x  n  r  c  . 

H.  II.,  white,  agetl  forty-two,  .single.  Admitted  March  18;  discharged 
April  22,  1899.  One  sister  had  had  uterine  niyomata,  another  sister  an  ovarian 
cyst.  The  i)atieiit  had  a  soft  systolic  luurniur  in  the  pulmonic  area  and  at  the 
apex,  which  was  jin^hably  hemic. 

Operation,  March  20,  1899.  A  large  tumor  was  found  wedged  in  the  pelvis. 
The  mass  was  gradually  lifted  and  enucleation  begun  on  the  left  side.  There 
was  a  hematoma  containing  120  c.c.  of  thick,  tarry  fluid  on  that  side.  On 
reaching  the  pelvic  floor  on  th(^  left  side  dense  adhesions  were  discovered  between 
the  tumor  and  the  sigmoid.  These  were  freed  with  scissors.  On  cutting  them 
across  ami  rolling  the  tumor  out  it  was  found  that  a  large  vessel  passed  directly 
from  the  sigmoid  into  the  tumor.  The  o])eration  was  com])leted  in  the  usual 
way.     The  highest  postoperative  temperature  was  100.5°  F. 

Gyn.  No.  7226. 

A  m  y  o  m  a  t  o  us  u  t  e  r  u  s  v  e  c  e  i  v  i  11  g  w  e  1 1  -  d  e  v  e  1  o  p  e  d 
blood-vessels  from   the   sigmoid   fl  e  x  u  r  e  . 

M.  J.,  colored,  aged  thirty,  single.  Admitted  September  22;  discharged 
November  4,  1899. 

Operation.  Hystero.salpingo-oophorectomy.  The  operation  was  complicated 
by  dense  adhesions  reciuiring  a  great  deal  of  dissection.  There  was  a  cystic 
myoma,  the  size  of  an  orange,  dark  blackish  green  in  color.  This  lay  just  in  the 
median  line,  above  the  l)rim,  and  was  attached  to  the  tumor  propc^r  by  a  pedicle 
2  cm.  long.  It  had  become  twisted  on  itself  once  and  was  evidently  under- 
going necrosis.  Firmly  adherent  to  this  mass  at  its  upper  margin  were  two 
separate  coOs  of  intestine.  The  ileum  everywhere  else  above  the  brim  was  per- 
fectly free.  The  bladder  was  drawn  high  up  over  the  nodule.  The  uterus  was 
removed  from  left  to  right.  The  adhesions  from  the  sigmoid  flexure  to  the 
tumor  contained  large  well-developed  vessels.  These  were  tied  both  ways  and 
separated.  The  tissues  were  exceedingly  vascular.  (Ireat  difhcully  was  ex- 
perienced in  liberating  the  bladder,  and  the  utmost  care  was  exercised  to  avoid 
injuring  the  ureters.  In  this  case  a  second  operation  was  necessary  on  accomit 
of  kinking  of  the  ileum  causing  partial  obstruction.  The  patient  was  in  a  very 
weak  condition.     The  tumor  weighed  14  pounds.     She  gradually  recovered. 

Path.  No.  348().  The  specimen  consists  of  the  enlarged  uterus,  with 
its  appendages.  The  uterus  is  nodular,  apjiroximately  13  cm.  in  diameter. 
Attached  to  its  surface  are  muuei-ous  vascular  adhesions.  Springing  fi'om  it  are 
several  pedunculated  and  sessile  nodules.  The  largest  pedunculated  tumor, 
both  in  shape  and  size,  bears  a  strong  resemblance  to  a  spleen  (Fig.  31).  It 
measures  12  x9  x  7  cm.,  and  is  attached  to  the  surface  of  the  utems  by  a  delicate 


PARASITIC    UTHRIXE    MYO.MATA. 


45 


pedicle,  1.5  x  0.7  cm.  On  section,  the  s])leen-shaped  nodule  presents  a  dark, 
reddish-brown,  glistening  appearance  and  is  traversed  by  fibrous  bands  of  a 
pinkish  color.  The  uterus  contains  interstitial  nodules  varying  from  a  pea  in 
size  to  5  cm.  in  diameter.  The  largest  of  these  is  undergoing  necrosis.  The 
uterine  cavity  is  8.5  cm.  in  length.  The  mucosa  is  smooth  and  glistening,  but 
not  more  than  1  mm.  in  thickness.  The  right  tube  is  normal.  The  left  tube 
and  both  ovaries  are  covered  with  adhesions. 

Microscopically,  the  nodule  described  as  resembling  a  spleen  presents  large 
areas  of  coagulation  necrosis  accompanied  by  hemorrhage.  In  the  degenerated 
areas  the  blood-vessels  are  much  dilated.  It  is  only  in  the  outlying  portions  of 
the  growth — in  oth(>r  words,  in  the  capsular  portion — that  the  typical  myoma- 
tous tissue  is  preservetl.  It  was  this  myoma  that  had 
twisted  and  was  undergoing  degeneration. 

Gyn.  No.  9078.     Path.  No.  5234. 

Multinodular  myoma  t  o  u  s  u  t  e  r  u  s 
\\-  i  t  h  a  subperitoneal  pedunculated 
nodule,  j)  a  r  t  i  a  11  y  parasitic,  under- 
going suppuration  and  communi- 
cating   with   the  cecum   (Fig.  32). 

E.  C,  white,  aged  thirty-six.  Admitted  Sep- 
tember 21;  discharged  October  30,  1901.  (For  the 
patient's  former  admissions  to  the  hospital  see  Nos. 
7315  and  8992.)  Complaint:  abdominal  tumor  and 
uterine  hemorrhage.  The  patient  began  to  menstru- 
ate at  fifteen,  was  always  regular,  with  a  ])rofuse  flow 
lasting  at  least  seven  days.  She  had  a  miscarriage 
nine  weeks  before  admission,  and  since  that  time  she 
has  had  constant  bleeding.  She  has  been  married 
sixteen  years  and  has  had  two  children,  fifteen  and 
ten    years    respectively.      Two    years  ago   she    was 

admitted  to  the  hospital  and  an  ether  examination  was  made.  At  that  time 
three  myomata  w(>r(>  detected.  For  some  time  before  this  the  patient  had  shai  p 
pains  in  both  groins.  Following  the  ether  examination  the  patient  feh  \-ei\-  well 
until  she  became  pregnant  in  April.  Since  then  slie  has  had  bearing-down  jtains, 
aching  and  throl)bing.  These  pains  became  much  more  severe  at  the  time  of  her 
miscarriage  and  liave  continued  since.  She  has  lost  30  pounds  in  weight  during 
the  last  six  months. 

On  examination  she  is  not  very  \k\\(\  despite  the  history  of  heniovriiages. 
The  hemoglobin  is  50  percent. 

Operation.  Ilysteromyomectoiny,  right  o(")phorectomy,  appendectomy,  sului'e 
of  cecum.  The  patient  during  the  o])eratioii  was  in  such  a  pi'eearious  condition 
that  ether  had  to  be  dis{'ontinue(l.     The  fundus  was  found  nuslied  somewhat  to 


Fig.  31. — A  Si'lkkn-shai'kd  My- 
oma. 
Gyn.  No.  7226.  Path.  No.  34Sti. 
This  myoma  had  undergone  tor- 
sion. It  showed  areas  of  necrosis 
and  had  become  adherent  to  the 
intestinal  loops. 


46 


MYOMATA    OF    TUK    UTERUS. 


the  right  l)y  an  intraligaiiicntary  iiiyoina.  To  the  right  was  a  second  myoma 
rising  from  the  cornii,  covered  by  omentum  and  very  adherent.  From  this 
a  thick  fil)rous  hand  })assed  to  the  small  bowel.  The  myoma  attached  to  the 
right  cornii  had  a  rather  pale  gray  color  and  looked  necrotic.  Its  pedicle  was 
very  long  and  was  easily  twisted  oft'  from  the  uterus  without  any  bleeding,  the 
tumor  api)arently  having  drawn  its  l;)lood-supi)ly  from  the  omentum.  It  rested 
on  the  head  of  the  cecum  but  was  not  very  adherent  to  it,  and  during  the  at- 
tempt to  separate  the  adhesions  an  opening,  o  mm.  in  diameter,  was  detected 


-'^"^ 


Fig.  32. — \  Suppurating  Subperitonkal  Myoma  Communicating  with  the  Lumen  of  the  Cecum. 
C'lyn.  No.  9078.  Path  No.  52.34.  The  uterus  is  somewhat  enlargeil,  owing  to  the  jiresenee  of  a  myoma, 
which  projects  into  the  left  broad  Hgameiit.  Attached  to  the  fundus  near  the  right  t\il)e  is  a  i)e<lunculated  myoma, 
which  mea-sured  7x5  cm.  Plastered  to  its  surface  and  furnishing  considerable  nourishment  is  the  densely  ad- 
herent omentum.  The  center  of  the  myoma  contained  an  abscess  cavity  which  opened  directly  into  the  cecum. 
The  myoma  has  been  dissected  free  from  the  cecum,  so  that  the  opening  is  clearly  seen  at  a. 


reaching  from  th(>  cecum  to  a  cavity  in  the  tumor  (Fig.  .32).  The  remaining 
adhesions  were  freed  and  the  myoma  was  removed.  The  right  tube  and  ovary 
and  ajipendix  were  brought  into  view.  The  apjiendix  was  buried  in  more  or 
less  necrotic  tis.sue  along  the  head  of  the  cecum.  It  was  gradually  dissected  out 
and  its  stump  cut  off  flu.^h  with  the  wall  of  the  cecum  and  then  this  and  the 
fistulous  tract  were  turned  in  with  nuiiierous  buried  silk  sutures.  Enucleation 
of  the  uterus  from  left  to  right  was  rather  easily  carried  out.  A  gauze  drain  was 
left  in  and  carried  down  to  the  head  of  the  cecum.  The  ])atient  gradually 
recovered  and  left  the  hospital  in  good  condition. 


PARASITIC    UTERIXK    MYoMATA, 


47 


Path.  No.  523  4.  The  spcciincn  consists  of  a  suhjH'ntoneal  myoma, 
which  was  partially  ])arasitic  and  ojjcncd  into  the  cecum.  The  tumor  is  ovoid 
in  shape,  7  cm.  long,  5  cm.  in  its  broadest  diameter.  Its  surface  is  rough,  and 
shows  innumerable  small  tags  of  adhesions.  At  one  ]X)int  the  old  pedicle  can 
be  made  out.  Attached  to  the  tumor  is  a  considerable  amount  of  omentum,  and 
to  the  feel  the  tumor  is  yielding.  On  section  a  firm  fibrous  capsule,  3  mm.  thick, 
is  evident.  Inside  this  the  tissue  is  less  firm,  yellowish  in  color,  and  apparently 
undergoing  degeneration. 

Another  portion  of  the  specimen  consists  of  the  uterus  and  adherent  tumor, 
both  tubes,  and  the  right  ovary.  The  mass  measures  11  xS  cm.  The  intraliga- 
mentary  myoma  on  the  left 
side  measures  7x7x5  cm. 
The  left  tube  is  uniform  in 
diameter,  13  cm.  long,  and  at 
its  distal  portion  has  been  con- 
verted into  a  small  cyst .  On  the 
right  side  the  tube  and  ovary 
are  closely  bound  together. 

Histologic  Examination. — 
The  necrotic  myoma  whicli 
communicated  with  the  bowel 
has  broken  down  and  is  in- 
filtrated     with      polymorpho-        Fig.    .33.— a    Mvoma    Reckivinc.    its    Nourishmknt    from    the 

nuclear  leukocytes  and  small  mesexterv  op  the  smal.  bow^.  and  coktainikg  an-  abscess 

•^  Cavity  which  Communicated  with  the  Lumen  of  the  1n- 

round   cells.     It    shows    evi-  testine. 

dence   of    chronic   inflamma-  ^'■':'^^'''^"'''''"'- -rt^lr^'-^^^t^J^ 

myoma  at  one  time  was  uterine.      The  uteru^^  wa.s  nearlj   normal  in 

tion.       The     appendix     is     the         size  and  projecting  from  its  surface  was  a  small  myomatous  mxlule. 

„  ,  .  ]••<-•  ^^'^  parasitic  myoma  measured    12  cm.   in  diameter  and   was  at- 

Seat  of   a  chronic  appendicitis.         tached  to  the  uterus  by  a  few  adhesions.      It  received  nearly  all  of 

its  blood-supply  from  the  mesentery  of  the  small  bowel.  Its  central 
portion  had  been  converted  into  an  abscess  cavity  10  cm.  in  diameter, 
which  communicated  with  the  lumen  of  the  bowel  by  an  opening 
2  cm.  in  diameter.  The  fecal  matter  passed  freely  into  aii.l  fmm  the 
myoma,  as  indicated  Viy  the  arrows. 


a  11  d     ()  p  e  11  1  11  g 


into      t  li  e 


D  r.  J.  Mason  Hund- 
ley's case   of   a   pa  r  a  - 
s  i  t  i  c    m  y  o  m  a    u  ii  d  e  r- 
going     sup  |)  u  rati  o  n 
small  bowel    (Fig.  33). 

M.E.C.,  white,  aged  thirty-nine,  single.  She  was  never  robust,  but  had  no 
serious  illness  until  July,  1900.  In  this  year  .she  began  to  have  irregular  uteriiu" 
hemorrhages,  which  were  very  jirofuse.  She  had  a  sinking  s|)ell  and  from  that 
time  gradually  grew  weak  and  lost  flesh.  In  March,  l'.)()3.  she  had  a  fall,  and  the 
injuries  sustained  necessitated  lier  icni:iining  in  bnl  I'oi'  several  weeks.  While 
in  bed  she  passed  a  numbei'  of  large  bloody  stools,  had  fever  aiul  chills,  ami 
suffered  with  abdominal  p;iin. 

Adiagnosis  of  tuinoi-  of  the  uterus  had  i)e<'n  made  in  l'"el)ruar>-.  VM)'!.  and  again 
in  1004.     An  operation  was  not  advised,  as  it  was  thought  that  the  tumor  would 


48  MVo.MATA    OF    THK    ITKRUS. 

cease  to  give  trouhlc.  Dr.  Iluiullcv  saw  the  ])ati('iil  on  Deceinlier  5,  1904,  and 
advised  operation. 

Operation.  T)eeenil)er  12.  1904.  The  luiiior  seemed  to  be  adherent  every- 
where, Init  in  reahty  it  was  attaehed  to  the  uterus  merely  by  a  few  slender 
adhesions.  It  had  a))pai'ently  originated  in  tlie  ])osteri()r  wall  of  the  uterus. 
Its  bloo(l-supi)ly  was  now  derived  from  a  portion  of  the  ileum  (Fig.  33),  which 
supplied  vessels  as  large  as  the  radial  artery.  The  lumen  of  the  adherent  portion 
of  the  bowel  comnuniicated  with  the  cavity  in  this  tumor,  and  the  cavity  in  the 
myoma  contained  grape-seeds  and  fecal  matter.  About  five  inches  of  the  bowel 
were  resected.  The  i)atieiit  died  thi-ee  (la\'s  later,  but  at  autopsy  there  was  no 
evidence  of  infection. 

The  i)ai"asitic  cyst  is  12  cm.  in  diameter  and  the  cavity  in  its  longest  diameter 
is  10  cm.  The  cavity  connnunicated  with  the  lumen  of  the  gut  b}'  an  opening 
2  cm.  in  diameter.  Its  walls  are  soft  and  ulcerated.  The  growth  received 
a  rich  blood-supj)ly  from  tlie  intestine.  Sections  from  numerous  areas  of 
the  abscess  wall  show  that  it  is  composed  of  very  dense  myomatous  tissue. 
It  is  va.scular  and  highly  inflamed.  There  is  no  evidence  of  sarcomatous  trans- 
formation. The  intestinal  walls  near  the  attachment  of  the  growth  show  an 
extensive  inflammatory  process  and  marked  vascularity. 

In  this  case  it  is  difficult  to  say  with  absolute  certainty  how  long  the  myoma 
had  connnunicated  with  the  bowel,  but  the  passage  of  a  number  of  large  bloody 
stools  in  1903,  accompanied  by  the  elevation  of  temperature  and  pulse,  strongly 
indicates  that  there  was  an  opening  between  the  two  at  this  period. 


ADVENTITIOUS  VESSELS   FROM  THE    BLADDER  SUPPLYING  NOURISHMENT  TO 

UTERINE   MYOMATA. 

One  of  the  first  questions  the  surgeon  asks  himself  before  making  an  abdominal 
incision  when  a  myomatovis  uterus  exists  is,  ''Is  the  bladder  high  up?"  This 
dislocation  of  the  bladder  is  fully  dealt  with  in  another  (•ha])ter,  and  here  we  are 
chiefly  interested  in  the  l)lood-sup{)ly  that  the  bladder  or  its  arteries  may  furnish 
to  a  neighb(iring  myoma.  In  our  series  only  seven  myomata  derived  any 
appreciable  amount  of  nourishment  from  the  bladder. 

In  Case  12194  a  large  multinodular  uterus  was  present.  The  ovarian  and 
uterine  blood-vessels  were  greatly  distended.  Rising  from  the  anterior  portion 
of  the  uterus  was  a  myoma  with  little  or  no  uterine  attachm(>nt.  It  apparently 
derived  its  blood-.supply  from  the  tissues  surrounding  the  l)la(lder. 

In  Case  7739  a  tumor  filled  almost  the  entire  abdominal  cavity.  Much 
nourishment  was  furnished  by  the  omentum,  but  a  portion  was  contributed  by 
very  vascular  adhesions  from  the  bladder  and  from  the  anterior  and  left  lateral 
abdominal  wall. 

The  bladder  in  Case  3842  was  so  intimately  attached  to  the  tumor  that  a 
piece  1x6  cm.  was  excised  with  the  growth.  In  this  case  omental  and  in- 
testinal adhesions  also  existed. 


PARASITIC    UTERIXE    .MYOMATA.  49 

Prolxil)lv  the  most  extensive  vesical  ])l()()d-su|)])ly  to  a  myoma  that  one  is 
likely  to  encounter  was  noted  in  Case  P.  (Fig.  25,  p.  o()).  Here  the  bladder  was 
drawn  high  up  into  the  abdomen,  and  from  its  posterior  surface  many  large  and 
tortuous  vessels  passed  to  the  tumor. 

In  Case  578-4  (Fig.  22,  p.  28)  the  l)ladder  supplied  its  (juota  of  blood  to  the 
myomatous  uterus.  Here  there  were  large  tortuous  vessels  emerging  from  the 
pelvis  and  entering  the  tumor. 

In  Case  6915  the  bladder  also  apparently  supplied  many  vessels  to  the  en- 
larged uterus.  In  one  of  our  recent  Hagersto^A7i  cases  (Fig.  34)  numerous  vessels 
passed  from  the  bladd(>r  to  two  subperitoneal  myomata. 


Gyn.  No.  12 194.     Path.  No.  8776. 

A  multinodular  m  y  o  m  a  t  o  u  s  u  t  e  r  u  s  with  one  of  its 
nodules  d  e  r  i  a'  i  n  g  its  chief  b  1  o  o  d  -  s  u  p  })  1  y  from  the 
tissues    surrounding    t  h  e    b 1  a  d  d  e  r  . 

S.  C,  colored,  aged  thirty-nine,  married.  Admitted  June  19;  discharged 
July  28,  1905. 

Operation,  June  21 ,  1905.  Hysterectomy,  double  salpingo-oophorectomy,  and 
appendectomy.  The  large  myomatous  uterus  was  easily  delivered.  One  nodule 
rose  from  the  posterior  part  of  the  fundus  and  was  about  the  size  of  an  adult's 
head;  another  had  originated  from  the  anterior  part  of  the  uterus  low  down 
near  the  cervix.  This  had  drawn  the  bladder  reflection  of  the  i)eritoneum  high 
up  over  the  tumor  mass.  All  the  pelvic  vessels  were  greatly  distended.  The 
uterus  was  removed  in  the  usual  way.  The  tumor  arising  from  the  anterior 
part  of  the  uterus  was  nearly,  if  not  entirely,  parasitic.  Its  connection  with  the 
uterus  itself  was  very  slight.  It  had  derived  its  blood-supply  a])})arently  from 
the  tissue  surrounding  the  bladder. 

The  highest  postoperative  temperature  was  100°  F. 

Gyn.  No.  7739. 

A  m  u  1  t  i  n  o  d  u  1  a  r  m  y  o  m  a  t  o  u  s  uterus  w  i  t  h  dense 
omental  a  d  h  e  s  i  o  n  s  ,  also  v  e  r  y  v  a  s  c  u  1  a  r  a  d  h  e  s  i  0  n  s 
fro  m  t  h  e  b  1  a  d  d  e  r  a  n  d  f  r  o  m  t  h  e  a  11  t  e  r  i  o  r  and  left  lat- 
eral  a  b  d  o  m  i  n  a  1   w  alls. 

M.  R.,  colored,  aged  twenty-nine.  man-ic(l.  ()i)erali()n.  Hysterosalpingo- 
oophorectomy  and  i-emo\al  of  tumor  of  the  i-iglit  ovaiy.  The  abdomen  was 
nearly  filled  with  a  large  solid  tumor.  The  omentum  was  everywhere  adherent. 
Some  of  the  vessels  were  the  size  of  a  little  linger  and  looked  just  like  large  worms. 
The  tumor  was  adhei'ent  to  the  bladder,  the  antei'ior  and  left  lateral  alxlominal 
walls.  These  adhesions  were  exceedingly  vascular.  The  patient  was  well  when 
discharged. 


50 


MYOMATA    OF   THE    I'TKRUS. 


Gyn.  No.  3842. 

D  (.'  11  s  (>  :i  (1  h  (•  s  i  0  n  s  b  c  t  w  e  e  n  t  he  hi  a  d  d  c  r  a  11  d  a  in  y  o  - 
III  a  tons  II  t  I'  r  II  8  . 

]■].  \\.,  colored,  -dgcd  lifty-two,  inarricd.  Admitted  October  2;  discharged 
November  <),  1S95.  ()])erat ion  October  10,  1895.  Hysteromyomectoiiiy.  The 
hirge  myomatous  uterus  liad  drawn  the  bhulder  almost  to  the  umbilicus.  The 
adhesions  between  the  tumor  and  the  bladder  were  so  dense  that  a  piece  of 
bladder  1  x  (5  cm.  was  excised,  and  the  wound  closed  with  four  mattress  sutures. 
There  were  also  adhesions  to  the  omentum,  intestines,  and  rectum.  The  patient 
was  Avell  when  discharged. 


Fig.  34. — PEDr.NCUL.\TKi)  Myomata  Receiving  a  Large  Part  of  Their  Nourishment  from  the  Bladder. 
C.  G.,  seen  in  consultation  with  Dis.  Preston  and  Victor  Miller  at  the  Hagerstown  Hospital,  June  14,  1907. 
Pa-ssing  from  the  bladder  to  the  two  myomata,  and  hiding  the  fundus,  were  broad  adhesions  (a)  carrying  large 
blood-vessels.  Adhesions  and  blood-vessels  (b)  also  passed  from  one  tumor  to  the  other.  The  tumors  were 
attached  to  the  uterus  by  relatively  small  pedicles 

C.  G.  (Hagerstown,  Md.). 

Ted  u  n  c  u  1  a  t  e  d  in  y  o  m  a  t  a  r  e  c  e  i  v  i  n  g  a  large  \)  a  r  t  of 
t  h  e  i  r   1)  1  o  o  d  -  s  u  ])  p  1  y   f  r  o  m   the   b  1  a  d  d  e  r  (Fig.  34). 

C.  ('..,  coloretl,  aged  twenty-eight,  seen  with  Drs.  Preston  and  \'ictor  Miller, 
of  Hagerstown,  June  14,  1907.  This  patient  had  a  large  myomatous  uterus. 
( )n  opening  the  abdoiiicn  we  immediately  encountered  large  vessels  running 
fi-oni  the  bladder  into  a  subperitoneal  myoma.  In  the  adhesions  there  were  at 
least  three  or  four  arteries.  The  myoma  itself  was  the  size  of  a  child's  head. 
Immediiitelv  behind  the  uterus  was  a  nodule  similar  in  size,      l^'roni  this  to  the 


PARASITIC    UTERINE    MYOMATA.  51 

other  nodule  passed  an  artery  at  least  5  nun.  in  diameter,  also  several  smaller 
ones.  We  liberated  the  bladder  adhesions  and  did  a  complete  hysterectomy. 
The  patient  stood  the  operation  well  and  made  a  good  recovery 

Vessels  from  the  Abdominal  "Wall  Furnishing  Abundant  Nourishment  to  a 

Partially  Parasitic  Myoma. 

Myomata  not  infrequently  become  adherent  to  the  lateral  or  anterior  abdomi- 
nal wall;  it  is,  however,  unusual  to  have  blood-vessels  of  any  appreciable  size 
passing  between  the  abdominal  parietes  and  the  myoma.  The  following  case 
proves,  however,  that  such  a  condition  occasionally  occurs. 

Gyn.  No.  15283. 

C.  B.,  colored,  aged  thirty.  Admitted  November  13,  1908.  Four  weeks 
before  entering  the  hospital  she  first  noticed  a  tumor  in  the  lower  abdomen. 
On  admission  her  abdomen  was  found  distended  by  an  irregularly  nodular 
mass  which  reached  4  cm.  above  the  umbilicus.  The  nodules  seemed  more  or 
less  fixed,  but  there  was  no  unusual  abdominal  tenderness  on  palpation. 

On  opening  the  abdomen,  one  of  us  (Kelly)  found  several  very  large  peduncu- 
lated myomata.  One  of  them  had  large  lymphatics  coursing  over  its  surface 
and  received  much  blood  from  the  omentum.  In  addition,  vessels  passed  from 
the  appendix  to  the  large  myoma  and  dense  adhesions  to  the  right  anterior  and 
lateral  abdominal  walls  furnished  many  vessels  to  the  tumor  (Fig.  35).  These 
vessels  were  very  abundant  and  paralleled  each  other  from  the  abdominal  wall 
to  the  tumor. 

Myomata  Extruded  from  the  Uterus  and  Lying  Free  in  the  Broad  Ligament. 
In  the  foregoing  pages  we  have  described  subperitoneal  myomata  that  have 
become  partially  or  completely  separated  from  the  uterus.  Occasionally  a 
myoma  that  has  been  extruded  into  the  broad  ligament  loses  its  connection  with 
the  uterus  and  receives  a  meager  blood-supply  from  the  tissue  in  whicli  it  lies. 
The  following  case  is  a  good  example  of  such  a  condition. 

Gyn.   No.  9674. 

M.  McM.,  white,  aged  thiit>-seven.  Admitted  May  27;  dischargetl  June 
20,  1902.  Menstruation  began  at  tiiirteen,  was  regular  and  modei-ate  in  amount, 
l^ecently  the  periods  have  l^'come  irregular,  the  ])atient  sometimes  going  four 
or  hve  months  without  any  nieiislrunl  flow.  She  has  been  niari'ied  eight  years, 
l^ut  has  never  been  ])regnant. 

Operation.  Kemoval  of  a  pai'asitie  niyoinn,  i-elense  of  .-idhesions,  multiple 
myomectomy,  suspension  of  the  uterus.  When  the  alxloinen  was  opened  the 
uterus  was  found  in  ret  roposition.  Thei-e  were  a  few  adhesions  about  the  left 
appcnidages.  Beneath  the  round  ligament  and  in  tiie  broad  ligament  was  a  hard 
tumor  the  size  of  a  small  egg.     It  was  sligiilly  movable.     The  peritoneum  was 


52 


MYOMATA    OF   THK    ITKUr.S. 


incised,  the  tumor  shelled  out,  and  the  hole  left    behind  closed  with  eatgut. 
Two  small  mvomala  of  the  fundus  were  shelled  out  and  the  incision  was  closed. 


Vessel*    from  append 


Tube' 


Rouncl  lig't.  Ovary 


K 


Fig.  35. — A  Multinodular    Myomatois  Uterus  with  Vessel.s  Passing   j-rom   the  Right  Abdominal  Wall 

AND  .\pPENDIX  to  A   LaRGE  PEDUNCULATED  MyOMA. 

Ciyn.  No.  15283.  Path.  No.  13199.  The  multinodular  myomatous  uteru.s,  with  its  attached  pus-tubes,  filled 
the  pelvis.  The  large  globular  pedunculated  myoma  was  free  from  omental  adhesions,  hut  was  attached  to  the  pa- 
rietal abdominal  wall  by  broad  adhesions.  Traversing  these  were  many  blood-vessels  which  passed  from  the 
tumor  to  the  abdominal  wall.     The  smaller  adhesions  also  contained  vessels,  but  of  less  caliber. 

The  appendix  was  adherent,  and  numerous  superficial  ai)i)endiceal  vessels  i)a.ssed  over  to  the  myoma.  Cover- 
ing the  surface  of  the  ajjpendix  were  clusters  of  small,  smooth-walled  cysts,  apparently  dilated  Ij-mphatics.  They 
were  particularly  abundant  near  the  cecal  junction. 


The  myoma  in  the  hroad  lifjament  had  no  appai'ciit  comicctioii  with  the  ligament 
itself  or  with  the  uterus.     The  i)atient  recovered  without  incident. 


CHAPTER  III. 

CERVICAL  MYOMATA. 

In  a  few  of  our  cases  the  myoniata  developed  low  down  in  the  l^ody  of  the 
uterus  or  in  the  cervix.  Such  growths  may  spread  out  in  front  of  or  behind 
the  cervix,*  but  arc  more  prone  to  separate  the  folds  of  the  broad  ligament,  thus 
becoming  in  part  intraligamentary.t 


Fig.  36. — Mydma  di-  Tiih;  Hhoau  I,ii;ami:\i  and  Ckuvix.      (  }  iiat.  size.) 
Gyn.  No.  5752.     Path.   No.  2055.     The  irregular   myoiiia,    10  x  13  c-iii.,   fills   the   left   broad    liRainent   and 
is  in  part  cervical.     In  such  a  case  control  of  the  left  uterine  ve.ssels  is  difficult.     The  cervical  canal  is  consiiierably 
distorted.     The  appendages  are  nninial. 


Cervical  myoniala  arc  of  inlciTst  cliiclly  from  a  clinical  stand|»oinl.  Tlicy 
mayso  block  Ihc  pcb'is  thai ,  wlici'c  pregnancy  exists.  ;i  normal  labor  is  out  of  the 
question    and   operati\-e  measures  nnist    be  undeilai^eii.      Thus,  in  case  (!.,  the 

*  Marked  c'cr\'icai  <l('\'('l()])iiH'nl  ol  iny(iiii;ii;i  was  rmicil  in  Cases  '-'Kit.  :-!'.l71.  lO'JL'.  .")7.'>-.  70.")'.). 
7240,  88GG,  97S0,  979S,  tOOod,  lOL'IJ,  aiul  I  IJl.i. 

t  Iiitraligamcntary  (lovcloimiciil  was  |>ail  iciilariy  |iniiniiiriit  in  Cases  .'i!t71.  117'-'.  I.S7(). 
4586,  5752,  G915,  7181,  and  9S2;i. 

53 


54 


MYOMATA    OF    THK    ITKIUS. 


pelvis  was  partly  Ijloeked  by  a  inyuiiia  that  had  developed  in  the  anterior  wall  of 
the  cervix  (Fig.  328,  p.  532).  After  abdominal  removal  of  the  myoma  the 
])alieiit.  who  was  four  months  pi-eti;naiit ,  proceeded  to  term  and  had  a  normal 
labor. 

Again,  when  hysterectomy  is  necessary,  the  uterus  is  often  found  firndy 
wedged  in  the  jx'lvis  and  its  removal  is  fraught  with  much  difficulty.  During 
the  shelling  out  of  these  tumors  exceptional  care  has  to  be  exercised  not  to  injure 
or  tic  one  or  ))oth  ureters,  as  they  are  so  intimately  connected  with  the  tumor. 
At  times  it  is  practically  impossible  to  dislodge  cervical  myomata  without  first 


Fig.  37. — A  Myoma  of  the  Broad  Ligament  and  Cervix.  (§  nat.  size.) 
Path.  No.  6920.  The  uterus  is  somewhat  enlarged,  owing  to  the  presence  of  small  myomata.  Extend- 
ing far  out  into  the  left  broad  ligament  is  a  globular  myoma.  Its  lower  half  is  cervical  and  extends  quite  a  dis- 
tance below  the  point  at  which  the  cervix  wa-s  amputated.  In  such  a  case  it  w^ould  be  best  to  control  the  right 
ovarian  vessels,  the  inght  round  ligament,  and  the  right  uterine  vessels,  cut  through  the  cervix,  and  then  catch 
the  left  uterine  vessels. 


bisecting  them.  Tiie  accompanying  illustrations  will  give  a  clear  conception 
of  the  various  forms  (A  cervical  myomata  encountered. 

In  Fig.  36  is  represented  a  myoma  which  fills  the  left  broad  ligament  and 
whose  lower  portion  is  cervical.  Th(>  uterus  has  been  distorted  and  pushed 
toward  the  right. 

Fig.  37  also  represents  a  myoma  Hlling  the  left  broad  ligament.  The  lower 
part  is  cervical,  and  extends  far  l)elow  the  level  at  which  the  cervix  has  been 
amputated.  Naturally,  much  difficulty  may  be  encountered  in  controllhig  the 
left  uterine  vessels  in  such  a  case. 

The  cervical  myoma  in  Fig.  3S  occupies  the  anterior  wall  and  spreads  out 


CKUVICAL   MYOMATA. 


55 


slightly  into  both  broad  ligaments.  The  cervical  mucosa  over  the  anterior 
wall  had  become  somewhat  atrophied  as  a  result  of  the  tension  and  it  will  be 
readily  seen  that  the  cervical  stump  was  much  bigger  than  usual. 

In  Fig.  39  we  have  not  only  a  myomatous  condition  of  the  fundus,  but  also 
a  general  myomatous  condition  of  the  cervix.  The  various  nodules  completely 
surround  the  small  cervix. 

Fig.  40  gives  an  example  of  the  marked  cervical  development  that  may  occa- 
sionally be  attained.     This  patient  (Gyn.  No.  9798)  for  a  year  had  had  i)ain  in  the 


M    y 


Fk;.  :5S. — A  ("khvicai.  Mvoma.     (^  nat.  size.) 
Gyn.  No.  ;ii)71.      I'lith.  No.  977.     The  upper  part  of  the  liody  of  the  uterus  ami  the  ap|)ciiihiKe.s  are  imrmal. 
Occupying  the  anterior  portion  of  the  cervix  and  liulRinR  into  the  cervical  canal  is  a  myoma,  I  1  cm.  in  diameter. 
The  cut  surface  of  the  cervix  was  naturally  larger  than  usual,  being  4.5  cm.  in  diameter. 


lower  abdomen  and  b;ick;iclic  and  her  jx'fiods  had  been  more  profuse  and  of 
longer  duration  than  before.  Thei'e  was  fretiueiicy  of  urination,  with  almost  loss 
(jf  control.  The  N'aginal  \auh  w.is  occu|)ied  by  a  myomatous  eeiAix  and  the 
cervical  canal  was  i-epreseiited  by  a  small  slit,  .\nterioiiy  and  to  the  I'ight 
the  mass  could  be  nio\'e(l  about,  but  not  ])ushed  u|)  out  of  the  pebis.  rpward, 
the  tumor  extended  almost  to  (he  umbilicus.  A  glanci'  at  the  })icturt'  shows 
that  the  fundus  is  enlarged,  but  the  chief  increase  in  size  is  due  to  an  essentially 
cervical  myoma,  which   has   originate(l   in    the   posterior  wall   and   literally  un- 


56 


MYO.MATA    OF    THK    UTERUS. 


folded t lie  cxtcnial  os.     It  wasncccssaiT  not  only  to  remove  the  uterus  ('onij)letely, 
but  also  to  excise  with  it  a  portion  of  the  x'a.irinal  nuicosa. 

Fiu'.  41  i-e])re.sents  a  myoma  that  was  lirnily  fixed  in  the  pelvis  and  HMjuired 
not  only  much  ])atie!ice,  hut  also  rapid  work  in  its  i'em()\-al.  The  tumor 
had  grown  from  the  anterior  surface  of  the  uterus  and  cervix  and  filled  Douglas' 
sac  almost   eompletelw      In   this  case  the  bladder  occupied  the  lower  angle  of 


Fig.  39. — Ckrvical  Development  of  Myomata.  (I  nat.  size.') 
Ciyn.  No.  97S0.  Path.  No.  5996.  The  body  of  the  uterus  contained  several  small  myomata  and  was  partially 
covered  with  adhesions.  The  right  tube  and  ovary  are  adherent.  Occupying  the  lower  part  of  the  body,  and 
extending  out  into  the  left  broad  ligament  and  surrounding  the  cervix,  are  myomata.  Those  on  the  left  siile  ex- 
tend below  the  point  at  which  the  cervix  was  amputated.  The  uterus  was  removed  from  right  to  left.  The  left 
ureter  was  exposed  for  a  distance  of  5  cm. 


the  incision  and  extended  Ki  cm.  above  the  symphysis.  The  blailder  was 
liberated  and  jmshed  down.  The  left  ovarian  vessels  were  ligated,  the  left  round 
ligament  was  controlled  and  cut;  the  corresponding  structures  of  the  right 
side  were  then  dealt  with  in  a  similar  manner.  The  right  uterine  artery  was  now 
found  and  ligated  on  the  .surface  of  the  tumor.  Th(>  operator,  not  being  able  to 
enucleate  further,  cut  through  la>'er  after  layer  of  the  uterine  tissue  until  the 
tumor  |)ropei'  was  readied,  aflei'  which  completion  of  the  enuck^ation  was  easy. 


CERVICAL    MYOMATA. 


Ot 


Ce  rv'i  cat 
Cft  nal 


Submuc  ous 
my  0  ma 


I  Hi.  10.  A  N'l.iiv  I. Mil ; I.  Ci  i<\  i(  \i,  M  vi)\i  \.  1 7  nut.  sizi-.  1 
('■yii.  Nil.  !l7ilS.  I'alh.  N'n.  tiOi:?.  The  IhhIn  nf  llic  ulcnis  i-  (•(ui-iiliTahly  enlnrtjcil.  'V]n-  icrvix  is  occiipiod 
by  a  very  larRP  ami  a|)iir().\iiiiatcl.\-  k1"1'IiIi"'  iiias.s,  wliicli  occupies  the  atitcrinr  wall  and  liulncs  into  the  cervical 
canal,  literally  uiifolilinK  it.  .\n  irreRiilar  ciitT  of  vaninal  mucosa  was  removed  with  Ihe  uterus.  The  uterine 
vessels  were  tied  hiiih  up.  'Vhv  vaKinal  veins  were  carefully  clamped  a.s  encountered  and  hence  little  bleeding 
occurred  during  the  operation. 


58 


.MVdMATA    OF   THK    ITKIU'S. 


The  va<iina  was  widely  ()j)ciicd.  Un  the  ciirlith  day  tlic  patient  had  signs  of 
cardiac  dilatation  with  ahnost  complete  anuria.  Xeverthcless,  she  made  a 
irood  recovery. 


Cysts 


Fig.  41. — Extensive  Cervical  Development  of  a  Myoma.     (?  nat.  size.) 
Gyn.  No.  7240.   Path.  No.  3502.     The  normal  fundus  and  the  practically  normal  appemlages  are  perched  on  the 
upper  surface  of  a  large  myoma,  which  occupies  Douglas'  pouch  and  extends  out  into  the  broad  ligaments.     The 
left  uterine  vessels  are  clearly  seen  on  the  side  of  the  tumor.     Attached  to  the  surface  of  the  tubes  are  a  few  small 
subperitoneal  cysts.     On  the  left  side  is  a  very  small  parovarian  cyst.     The  operation  wivs  a  very  difficult  one. 


(For  the  description  of  hi.section  of  the  uterus  as  [)ractised  in  some  of  these 
cases  see  page  608.) 


CHAPTER  IV. 


SUBMUCOUS  MYOMATA. 


Nearly  all  iiiyomata  arc  primarily  interstitial  and  are  gradually  forced 
toward  the  outer  or  inner  surface  of  the  uterus.  In  some  instances  the  uterus 
contains  only  one  myoma,  in  others  the  myomata  are  as  abundant  as  potatoes 
in  a  potato-hill.  As  a  rule,  only  one  myomatous  nodule  becomes  submucous, 
but  sometimes  the  entire  cavity  may  be  greatly  enlarged  and  literally  paved 
with  them. 

In  Fig.  42  is  shown  an  interstitial  myoma  which  has  grown  into  the  uterine 
cavity  and  fills  it  from  fun- 
dus  to   cervix.     The    uterus 
contained  this  single  myoma. 

Fig.  43  shows  an  enlarged 
uterus,  which  contains  num-     r^^^^^HP'  "--^w^  ""^ftA 

erous  interstitial  myomata, 
while  its  cavity  is  literally 
paved  with  small  myomatous 
nodules.  In  addition,  a 
mass  of  myomatous  tissue 
consisting  of  several  smaller 
myomata  is  pedunculated 
and  partly  fills  the  cavity  of  ^la.  42.— a  submucous  myoma  fim.ing  thk  riKniM;  cavuv. 
the  uterus. 

Tlic  submucous  develop- 
ment of  the  myoma  is  strik- 
ingly shown  in  Fig.  44.  One 
subj)eritoneal      and      several 

smaller  interstilial  nodules  are  seen,  but  the  great  increase  in  the  size  of  the 
uterus  is  caused  by  se\'ei'al  large  sulnnueoiis  myomata.  One  can  readily  see 
how  such  an  eiihii'ged  utei'us  might  in  tiinee\|)el  nearly  all  its  myomata.  and 
eventually  show  little  evidence  of  its  |)i-e\ious  size. 

Size. — The  submucous  myomata  ina>'  not  reach  oxer  1  em.  in  diameter. 
On  the  other  hand,  they  may  assume  very  large  pioixulions.  In  Case  Kit)'.), 
for  example,  the  suhniucous  tumoi'  was  so  lai'ge  that  the  uterine  caNity  was 
24  cm.  in  length. 

Pedunculated  M  y  o  m  a  t  a.  -  Since  the  suhnnicous  myomata  act 
as  foi'eign  bodies  and  ihe  uterus  manifests  a  decidecl  tendency  to  e\])el  them. 

59 


(5  nat.  size.) 

Gyn.  No.  ()S4;5.  Path.  No.  .3080.  The  uterus  was  the  size  of 
that  of  a  four  months'  pregnancy,  a  represents  the  cervical  portion. 
The  uterine  walls  are  of  the  normal  thickness.  ProjectinR  into  the 
cavity  and  filling  it  is  a  submucous  myoma  (b).  A  myoma  in  such 
a  po.sition  invariably  causes  severe  uterine  hemorrhage. 


Fio.  43. — Marked  Submucous  Developmknt  of  I'tkrink  Mvomata.  (§  nat.  size.) 
Gyn.  Nos.  S0.36  and  9203.  Path.  No.  5378.  One  tube  and  ovary  and  a  myoma  had  been  removed  per  ab- 
domen  five  years  before.  The  uterus  filled  the  pelvis  and  extended  6  cm.  above  the  symphysis.  Scattered  through- 
out the  walls  are  numerous  interstitial  myomata.  Lining  the  uterine  cavity  are  many  small  round  myomatous 
nwlules;  in  fact,  the  cavity  is  literally  paved  with  them,  a  is  the  upper  i)art  of  the  cavity.  Projecting  into  and 
partially  filling  the  cavity  is  a  conglomerate  mass  of  small  myomata. 

When  the  patient  entered  the  hospital,  her  hemoglobin  was  only  15   per  cent.     She  was  built  up  and  a  success- 
ful hysterectomy  performed  when  the  hemoglobin  had  reached  46  per  cent. 


Fig.  44. — E.xtensivk  Sub.mucois  Dkvklopmk.nt  of  Uterine  Myomat.\..     (5  nat.  size.) 
Gyn.  No.  8495.     Path.  No.  4716.     A  vaginal  myomectomy  had  been  done  three  years  previous  to  the  hyster- 
ectomy.    Projecting  from  the  fundus  is  a  pedunculated  subperitoneal  myoma  and   scattered  throughout  the  walls 
are  a  few  interstitial  nodules. 

Greatly  distending  and  completely  filling  the  uterine  cavity  are  three  submucous  myomata.  The  largest  one 
is  markedly  lobulated  and  sharply  outlined  from  the  uterine  walls.  The  two  others  are  sessile  and  one  of  them 
spreads  out  into  the  left  liro.-ul  ligament. 

It  is  interesting  to  note  that  for  the  jjrevious  four  months  the  flow  had  been  excessive  and  painful  and  that 
between  periods  the  patient  had  had  severe  labor-like  pains  lasting  from  three  to  four  hours.  Marked  exertion 
would  bring  on  the  pains.  The  largest  myoma  would  have  undoubtedly  soon  been  expelled,  provide  1  the  patient 
had  not  meanwhile  succumbed  as  a  result  of  the  severe  hemorrhages. 

60 


srBMUcors  myomata. 


61 


the  myoma  will  1)0  forced  more  and  more  into  the  cavity  and  li'radually  become 
pedunculated.  As  a  result  of  the  continued  uterine  contractions  it  ma}'  be 
forced  completely  out  of  the  uterus,  as  seen  in  Fig.  49.     Here  the  lobulated  and 


Fi(i.  45. — A  I,AU(iK  I'KDiNcri.ATKi)  SiHMi  I  <irs  MvoMA.     c'l  iiat.  size.) 
Gyn.  No.  fi43.3.      Path.  No.  2().5H.      The  nodular  myoiiiatou-  uI(mu>  hhmsuicmI    10  \   11    \    1 :{  <in.      I'rojoctiii); 
through  the  cervix  and  attached  by  a  broad-ba.sed  ])ediclp  is  a  lohulali'd  >uliiiniicais  ni.Mima.  S  \  U)  \  11  cm.      I'hc 
exact  relations  are  iti<licated  in  the  small  sketch  on  the  left.     The  m\oMia  sliuucd  a  good  deal  of  disintegration. 

The  patient  was  jjoorly  nourished  and  very  anemic;    her  face  had  a  drawn  e.xpressioii.     She  made  a  go<nl 
recovery. 


roughened  myoma  ])r()j('ct.^  from  the  cciA'ical  canal  and  the  cciAical  li|).-<  loi'iii 
a  collar  ai'oimd  il.'^  i)cijiclc.  The  pedicle  ol'  ,-;uch  a  iiiyoiiia  may  be  .•<e\'eral  centi- 
meters in  diameter,  but  is  often  atlenuated,  as  seen  in  I'ii::.  •'>(). 


62 


:my()mata  of  the  iterus. 


l'"r()iii  l-'iti.  4")  we  get  a  (jood  idea  of  a  lar^c  iiiyoina  which  jn-ojccts  from  the 
cervix  and  tills  the  vagina,  and  which  is  still  very  hrnily  fixed  as  a  result  of  its 
broad  basal  attachment.  Its  pedicle  would  in  tune,  however,  become  so  attenu- 
ated that  the  sul)nuicous  growth  could  be  removed  with  the  utmost  ease. 

In  Case  909  the  subnuicous  myoma  measured  7x8  cm.,  and  the  pedicle 
was  so  delicate  that  the  tumor  easily  rotated  on  its  axis.  In  Case  4382  the  pedicle 
was  even  more  attenuated,  the  myoma  becoming  completely  detached  during 
the  jJH'paratory  vaginal  wasiiing. 


Fic.  4ti. — A  Lakck  Pkdunculatkd  Submucous  Myoma.     (,^t  nat.  size.) 

C.  H.  I.     R.,  October  25,  1902.     Path.  No.  6226.     Projecting  through  the  cervix  and  completely  filling  the 

vagina  wa.s  a  large  lohulateii  submucous  myoma.     It  bled  so  freely,  anil  the  patient  was  so  blanched,  that  o])eration 

was  at  first  deemed  impossible.     The  dilated  but  otherwi.se  normal  cervix  is  clearly  seen.     The  body  of  the  uterus 

contains  numerous  small  myomata.     The  uterus  was  removed  per  abdomen  and  the  patient  made  a  good  recovery. 


In  Fig.  46  we  have  an  exam{)le  of  a  submucous,  ])('duiiculated  myoma, 
practically  as  large  as  the  myomatous  uterus  with  its  a{)pendages  combined. 
This  myoma  comj)letely  fillc(l  the  vagina:  it  bled  profusely  and  was  removed 
with  great  difficulty. 

A\  hen  the  uterus  contains  but  one  myoma  and  this  becomes  submucous  and 
pedunculated,  as  in  Fig.  48,  with  the  removal  of  this  growth  all  trace  of  jx'lvic 
disturbances  usually  disappears. 


SUBMUCOUS    MYOMATA. 


63 


Sloughing  Submucous  Myomata. 
(For  the  histologic  appearances  of  the  mucosa  covering  submucous  myomata 

see  page  312.) 

Many  of  the  submucous  nodules  undergo  i)artial  and  occasionally  complete 


Fii;.  47.— A  PonxioN  ok  a  Lauck  Intkustiti  ae.  Mvi.mv  that  has  lU.roMK  Sihmicovs  am)  Shows  Early  Sujns 

OF  Hrkakinc  Down.     (J  iiat.  size.) 
Cyn.  No.  «"<i9.     I'aili.  No.  .'i982.     The  uterus  is  pear-.shai)e<l  ami   mea-sures  1.5  x  IS  x  20  cm.     The  K^neral 
outlines  are  altered,  a.-*  the  left  tube  and  ovary  are  on  a  higher  kvel    than    the   right  appendages.     The   uterine 
cavity  hiis  heen  split  from  cervix  to  fundus.      FillinR  the  cavity   is  the  sul)muc()us  portion  of  the  tumor,  which  is 
lohulatcd  and  mottled  in  appearance.      .\t  h  it  shows  commenciiiK  dencneration. 


(iisiiilctiratioii.  This  breaking  down  may  occur  while  the  Iiiiiior  is  still  lying 
ill  th,.  uterine  cavity,  or  not  manifest  itself  until  the  myoma  has  been  forced 
into  the  vagina  or  has  e\-en  emerged  from  the  vauina. 


64  MYOMATA    OF    THK    ITKIU'S. 

Size. — SonictiiiR'S  the  tumors  arc  ywv  small,  not   rcachiuti;  ovvv  1  or  2  cm. 


f^t^VanL/^i^t^ 


Pedicle 


Fig.  48. — A    Laiuu:   I'kdunc  i  latkd  Submucous 
Myoma. 

Gyn  No.  8410.  Path.  No.  4.59.3.  The  body  of 
the  uteru-s  is  only  .slightly  enlarged.  The  cervix  is 
widely  dilated  and  the  vagina  greatly  distended  by  a 
lobulated  subuiucoii.s  myoma.  (For  details  of  the 
myoma  see  Fig.  49.) 


Fig.  49. — A  Lobulated  Submucous  Myo.m.\^  Pro- 
jecting Through  the  Cervix. 
Gyn.  No.  8410.  Path.  No.  4593.  The  vaginal 
discharge  was  extremely  offen.sive  and  brownish  in 
color.  Projecting  through  the  cervix  is  a  globular 
myoma  with  a  markedly  lobulated  surface.  The 
myoma  was  grayish  in  color  and  rather  soft.  It  was 
apparently  sloughing. 


ill    diameter,   but   not    infrt 
Pedicle 


;?{•>*- 


Fig.  50. — A  Gangrenous  Sub.mu- 
cous  Myoma.  (Nat.  size.) 
Gyn.  No.  7615.  Path.  No.  3879. 
This  lobulated  myoma  had  a  slender 
pedicle,  and  measured  1.5  x  .3.5  x  4.5 
cm.  It  was  mottled  in  appearance, 
having  dark  green,  gray,  and  reddish 
areas  .scattered  over  its  surface.  His- 
tologic examination  showed  that  the 
surface  was  covered  with  fibrin  and 
polymorphonuclear  leukocytes,  be- 
neath which  was  tyjiical  graiuilation 
tissue.  The  uterus  contained  another 
similar  liut  smaller  submucous  my- 
oma. 


'([ueiitly  are  of   goodly  .size   and  may  occasionally 
reach  the  large  proportions  seen  in  Fig.  52. 

The  sloughing  usually  commences  at  the 
most  dependent  part  of  the  tumor,  at  some 
point  mo.st  remote  from  the  source  of  hkwd- 
suj)ply  and  where  the  tumor  is  most  likely  to 
l)e  exposed  to  the  air.  In  Case  2732  (Path. 
No.  266)  we  have  an  example  of  the  early 
changes.  The  submucous  tumor  was  conical 
in  .shape,  measuring  2  x  3.5  x  7  cm.  Near  the 
pedicle  its  .surface  was  pale  pink,  hut  its  lower 
end  was  dark  brown  in  color  and  soft,  and  here 
and  there  the  surface  was  eroded.  In  Case  7237 
(Path.  No.  3491)  the  ut(>rus  was  greatly  enlarged, 
measuring  14  .x  20  x  21  cm.  Occupying  the 
cavity  of  the  uterus  and  {)rojecting  through  the 
cervix  was  a  submucous  myoma,  5x7x12  cm., 
with  a  broad  ba.sal  attachment.  Its  .surface  was 
slight!}'  lobulated,  granular,  and  somewhat  in- 
jected. Histologically,  the  surface  in  places 
showed  necrosis  and  some  j)olym()rphonuclear 
infiltration.     Fig.  47  represents   a    ])ortion    of   a 


SUBMUCOUS    -M Y(J.M ATA . 


65 


large  myoma  of  the  fundus  filling  the   uterine  cavity,  projecting  through  the 
cervix,  and  showing  early  signs  of  disintegration. 

AMien  the  mvoma  is  extruded  into  the  vagina,  it  often  forms  a  glol)ular 


ca-vity 


Cervjx- 


I-"ii;.  51. — .\  Si.orciiiiNc  Si  i;\ii  cdi  s  Mioma.  (  ■;  iiat.  size.) 
Gyn.  No.  7.')40.  rath.  No.  3799  Tlie  .•section  repie.seiil.'S  liiilf  of  the  uteru.--.  .Attached  to  the  surface  are  a 
few  adhesions  ami  in  the  neighborhood  are  two  small  myoinata.  OccupyiiiK  the  fundus  and  completely  (illiiiR 
the  uterine  cavity  is  a  myoma,  the  lower  ijortion  <>i  which  has  widely  dilated  the  cervix  and  extendeil  into 
the  vagina.  The  vaginal  ijortion  of  the  myoma  had  Lrckiii  <li>\vn  to  a  considerable  extent,  and  the  central  part 
of  the  tumor  is  necrotic.  In  time  the  greater  part  of  llic  niyoina  would  be  extruded  into  thevadina  if  the  patient 
did  not  meanwhile  succumb  to  sepsis. 


mass  with  a  I'ouglieiicd  surface  and  iiailially  cdNi'icd  wiih  a  pyogenic  nieinbrane, 
as  in   Figs.    I'.t  and  .')(). 

In  Case    l')")l    a   siihmucous  myoma    had   hccn    i'cnio\-cd   four  yeais  before. 


66 


MVOMATA    OF   THE    UTERUS. 


On  admission  to  the  hospital  the  myonialous  uterus  reaelied  the  uiuhilicus, 
while  projecting  from  the  vagina  and  directly  continuous  with  the  uterine  tumor 
was  a  gangrenous  mass. 

The  gangrenous  sul)mucous  myoma  in  Case  4668  (Path.  Xo.  lo27)  was  IS  cm. 
long,  and  from  1  to  7  cm.  in  diameter.     It  was  mottled  in  color,  being  green  or  red- 
dish yellow,  and  necrotic. 

The  large  submucous 
myoma  in  Case  6433  pro- 
jected through  the  cervix 
and  filled  the  vagina.  It 
measured  S  x  10  x  11  cm., 
and  was  attached  to  the 
uterine  wall  by  a  pedicle 
4  cm.  in  diameter.  This 
myoma  was  covered  with 
blood  and  fibrin  and  its 
surface  consisted  of  a 
greenish  pyogenic  mem- 
brane. 

The  inflammatory  pro- 
cess gradually  extends  to 
the  imderlying  myomatous 
tissue  and,  if  the  submu- 
cous myoma  has  a  broad 
basal  attachment,  portions 
of  the  tumoi-  may  be 
gradually  sloughed  off.  In 
Fig.  51  we  have  a  good 
illustration  of  .such  a  con- 
dition. Filling  the  uterine 
cavity  and  intimately 
blended  with  the  walls  is  a 
large  submucous  myoma. 
Its  lower  portion  has  un- 
dergone a  good  d(>al  of 
disintegration  and  the 
center  is  already  necrotic. 
When  the  process  advances  still  further,  we  find  a  grayish,  offensive,  tough, 
stringy  ti.'^.'^ue  projecting  from  the  vagina,  as  in  Case  6143.  Probably  the  most 
])i-oii()unce(l  instance  of  this  kind,  in  our  experience,  was  Xo.  11889,  described  in 
detail  on  page  577.  The  ])atient  was  almo.st  moribund.  Her  hemoglobin  was 
14  per  cent.;  the  temperature  was  104.2°.  The  myomatous  uterus  reached  the 
umbilicus.     Projecting  from  the  dilated  cervix  was  a  grayish-white  .sloughing 


Fig.  52. — X  Vkry  Large  SiB.Micors  Myoma  which  had  bkkn  Ex- 
truded FRO.M  THE  Uterus. 
H.  .\ut.  No.  2987.  The  patient  entered  the  hospital  in  a  desperate  con- 
dition. Operation  was  out  of  the  question,  and  she  died  in  a  few  days. 
During  the  interim  the  submucous  myoma,  which  protruded  slightly, 
was  forced  out  of  the  vagina.  The  myomatous  uterus  still  fills  the  pelvis, 
but  the  tumor  projecting  from  the  vulva  and  attached  by  a  broad  pedicle 
is  larger  than  the  uterus.  This  myoma  had  molded  itself  to  the  pelvis, 
otherwise  it  could  not  possibly  have  escaped  through  the  vagina. 


SUBMUCOUS    M Y(  )M ATA . 


6< 


,Pe  dicle 


submucous  myoma.     The  necrotic  })ortion  of  the  submucuus  myoma  \va>;  n 
moved,  and  the  patient  was  in  good  health  three  years  later. 

It  is  astonishing  what  large  myomata 
may  be  expelled  through  the  vagina. 
In  Fig.  52  the  transverse  diameter  of  the 
myoma  is  greater  than  the  distance  from 
the  symphysis  to  the  sacrum.  The  myoma 
was  soft  and  flabby  and  had  readily  ac-  b 
commodated  itself  to  the  jjelvis,  again 
assuming  its  former  shape  as  soon  as  it 
had  emerged  from  the  vagina. 

In  Fig.  53  we  see  the  mottled  appear- 
ance and  the  engorgement  freciuently 
noted  in  sloughing  submucous  nodules. 
The  dark  color  is  due  to  extravasation  of 
blood,  and  many  of  the  blood-vessels  are 
dilated  and  filled  with  thrombi. 

The  sloughing  subnmcous  myoma  in 
Case  6185  lay  between  the  thighs,  and  at 
first  suggested  a  prolapsed  uterus.  The 
growth,  however,  was  dark  l)i-()wiiish  green 
in  color  and  covered  with  a  bloody,  foul- 
smelling  discharge.  It  measured  15  cm. 
in  length  and  8  cm.  in  diameter.  The 
finger  entered  the  vagina  readily,  and 
the  pedicle  of  the  tumor  was  found  to 
spring  from  within  the  cervix  on  the  left 
side. 

The  odor  from  a  sloughing  subnmcous 
myoma  is  often  almost  unbeai'able;  even 
after  the  tumor  has  been  in  alcohol  for 
years,  the  disagreeal)le  stiiell  clings  to  the 
hands  for  hours  despite  tlu^  most  careful 
washing  and  the  use  of  deodorants. 

The    vaginal     discharge     is     likewise 
offensive.     Its     color     naturally     depends 
upon    the   abundance    of    polymorphonu- 
clear   leukocytes,   the  aniounl    of    disintcgi'ation,    and    lln 
watery,  dark  brown,  or  greenish  in  hue. 

(For  sloughing  subix'riloneal  and  intcrstilial  inyoniala  see  |)ag('  134.) 


It 

Fig.  53. — A  Si.oti;niM;  SrHMrcois  Myoma. 
(I   iiat.  size.) 

Gyn.  No.  7313.  Path.  No.  3(>73.  The  luy- 
oina  was  15  cm.  long  and  varied  from  3  to  5  cm. 
ill  diameter.  Us  lower  end  appearetl  RunKreii- 
ous,  and  the  tumor  liad  a  very  foul  odor.  The 
liicliHi'  rcprrsriil^  a  lonniliuiinul  section  of  the 
{growth.  The  siuall  pedicle  is  seen  at  the  top. 
At  a  is  a  small  polypoid  projection  of  the  myoma. 
The  tumor  presents  a  mottled  api>earanee,  and 
many  of  its  hlood-vessels  are  dilated  U>).  Hi.sto- 
Idnic  examination  .showe<l  that  the  surface  of  the 
myoma  wius  entirely  necrotic. 

The  uterus  was  removed  shortly  afterward 
and  sarcoma  foimd  U'-  I'-'J*-  '"'"'  I':i'''"mI  di^HJ  of 
pidmcinary  metastases. 


liciniilTlKme,    being 


68 


.MYO.MATA    OF    TIIK    UTERUS. 


fc^..,  - 

?">, 

«, 

';•  •  * 

v.^*:?      ■ 

1*     ^- 

i^  '^  -^r 

', 

^.%f.y- 

»«'\. .. 

;^/V'  "^.. 

, 

.V   V'.lVs* 

' 

• 

'C'. 


tv' 


Histologic  Appearances  of  Sloughing  Submucous  Myomata. 
As  the  niyuiiia  is  forced  more  and  more  into  the  uterine  cavity,  its  pedicle 
naturally  becomes  more  attenuated;  and  when  the  tumor  is  extiuded  into  the 
vagina,  it  is  more  liable  to  become  bruised,  so  that  the  likelihood  of  infection  be- 
comes greater.  The  breaking  down  of  the  tumor  usually  starts  on  the  surface 
and    graduallv    ti'avels    inward.      The    more     prominent     parts  of    th(>    tumor 

may  have  a  thin  covering  of  mucosa, 
or  this  may  have  already  entirely  dis- 
a{)))eared.  First  the  tissue  immedi- 
ately beneath  the  surface  shows 
some  small-round-celled  and  poly- 
morphonuclear infiltration  (Fig.  54). 
Occasionally  there  may  also  be 
edema,  as  in  Case  2593  (Path.  No. 
17S).  This,  however,  is  uncommon, 
as  the  tumor  is  subjected  to  pressure 
from  all  sides.  The  number  of  poly- 
morphonuclear leukocytes  and  small 
round  cells  rapidly  increases,  and  the 
surface  soon  shows  signs  of  disinte- 
gration. The  tissue  in  the  vicmity 
undergoes  complete  coagulation  ne- 
crosis, the  colorless  fibers  still  l)eing 
visible.  Occasionally  there  is  frag- 
mentation of  nuclei,  as  noted  particu- 
larly in  Cases  6143  (Path.  No.  2413) 
and  Gyn.  No.  7237  (Path.  No.  3491). 
The  blood-vessels  near  the  surface 
may  be  much  dilated,  as  in  Case 
2732  (Path.  No.  266)  and  Case  3066 

-The  Surface    of  a  SLOUCnixG   Submucous  ,       -.^  ,n,^\         t        ^i  f       i 

MvoMA.    (xnodiam.)  (P^th.  No.  460).     In   the  very   foul 

Gyn.  No.  6855.     Path.  No.  .3177.     o  i.<  the  .surface  sloUgllillg    grOWths     tile     blood-VeSScls 

of  the  growth,  con.si.sting  of  tis.sue  which  is  partly  necro-  .         ,  .  ,  ,         ^|,      > 

tic.     It  contains  a  few  distorted  polymorphonuclear  leu-  Ul  the  UCCrotlC    mUSClc    UUiy    bC    hllcd 

kocytes  and  small  round  cells.     In  the  underlying  tissue  ^^.jjj-^    organislUS    (Fig.   55),    aS    iu  CaSB 
a  few  muscle-fibers  are  still  visible,  and   there  is  much 

hemorrhage  (6).     In  the  depth  are  numerous  caidllaries  2732      (Path.      No.      266),      CaSC     4663 

(c).     The   tissue   shows    considerable    small-round-celled  ,  t-,    ,i        -^t         i  ootx      t^.r.        Kon/2     /"D^+U 

and  some  polymorphonuclear  infiltration.  (^  ^th.    No.     132/),    CaSC     o296    (Path. 

No.  1750), Case  7313  (Path.  Nos.  3576 
and  3673),  and  Case  11889  (Path.  No.  8297). 

As  the  inflammation  becomes  more  chronic  the  surface  will  be  found  covered 
with  fibrin,  polymorphonuclear  leukocytes,  and  blood,  while  the  underlying  part 
consists  essentially  of  granulation  tissue  (Fig.  56).  The  increased  vascularity 
diminishes  and  the  vessels  may  show  organizing  thrombi,  as  in  Case  6185  (Path. 
No.  2441);  or  the  vessels  may  be  already  obliterated,  as  in  Case  7237. 


Fig.  54. 


SUBMUCOUS    :\IYOMATA. 


69 


Occasionally  a  niyoiiia  that  has  already  shown  marked  hyaline  degeneration, 
as  it  becomes  submucous,  will  disintegrate  very  rai)idly  without  showing  nuich 


Necrotic,,    surface 


Fig.  55. — Thk  Suhkkkicial  Poktion.s  of  a  Sloughinc; 
Submucous  Myoma.     (X    140  diain.) 

Gyn.  No.  7549.  Path.  No.  .3799.  The  myoma  was 
approximately  15  cm.  in  length,  9  cm.  in  breadth.  The 
lower  portion  was  sloughing,  anil  projected  through 
the  cervix. 

The  .surface  i.-i  entirely  necrotic;  then  conies  a  ne- 
crotic zone  densely  inhltrated  with  small  round  cells  and 
polymorphoiuiclear  leukocytes;  heneatli  this  the  necrotic 
character  of  the  tissue  is  clearly  seen,  as  indicated  by  the 
area  a.  At  6  are  blood-ve-ssels  almost  completely  choked 
with  organisms. 


«iA 


v^:?^; 


Fi(..  Oli.  Till-  SiiUAU  "I  \  Si  ..I  ..iiiN^.  .•SUB- 
MUCOUS MvoMA.  (X  150  diam.) 
Gyn.  No.  7.383.  Path.  No.  3f.35.  The  .sub- 
mucous myoma  was  0  cm.  long,  4  cm.  broad. 
In  protected  places  the  mucosa  was  intact,  but 
:it  some  points  had  entirely  .lisappeared.  M  a 
the  surface  is  covered  with  hbrin  contaiiiiiig  blood 
;iriil  polymori>lii>nuclear  leukocytes  in  its  me-shes. 
I  he  underlying  tissue  {!>)  consists  of  typical  granu- 
lation ti.ssue.  Scattered  throughout  this  arc 
numerous  cai)illaries  (H).  r  is  the  unaltered  un- 
derlving  injcmialons  tissue. 


inflammatory  ivactioii.     This  was  ])articulaily  noticeable  in  ( 
No.  3491). 


(Pat 


70  MVO.MATA    OF    THK    UTKUUS. 

A  Sausage-shaped  Sloughing  Submucous  Myoma,  Three  Feet  in  Length. 

The  accoiiipanyiiig  case  is  unique,  and  dcnionstratcs  the  amount  of  ])r('ssure 
that  can  he  cxci'tcMl  l)y  the  uterine  muscle.  For  five  years  the  patient  had  l)een 
aware  that  a  uteiine  tumor  existed.  f)ut  only  towai'd  the  end  of  tliis  period  was 
there  evidence  of  a  suhmucous  growtli.  AA'itli  the  rapid  necrosis  of  the  tvunor  a 
hirge  portion  of  it  was  sj)eedily  ex})ened  l)y  the  uterus,  being  molded  in  its  exit  by 
the  cervix  until  it  formed  a  sausage-like  ma.ss  over  three  feet  in  length. 

I".  .1.  11.,  aged  thirty-eight,  colored,  admitted  to  the  Cambridge  Hospital. 
Md,,  January  13,  1907.  The  patient  had  always  been  well  and  strong,  but  five 
years  before  had  been  told  that  she  had  an  abdominal  tumor.  Three  days  before 
admission  to  the  hospital  she  was  seen  by  Dr.  ]'].  ]■].  AA'olff,  She  had  at  that  time 
a  temperature  slightly  over  101°  F.  A  large  nodular  mass  occupied  tlie  lower 
part  of  the  abdomen  and  there  was  some  abdominal  tenderness.  The  foul 
vaginal  discharge  still  continued.  Filling  the  vagina  was  a  rope-like  structure 
over  thi-ee  feet  in  length.  This  was  attached  within  the  uterine  cavity.  On  its 
lower  end  was  a  knob-like,  lobulated  mass,  3x5  inches.  After  the  vagina  had 
been  cleaned  up  as  thcM'oughly  as  possible  the  uterus  was  removed  from  above  by 
Dr.  Curtis  Burnam. 

After  operation  there  was  a  good  deal  of  vaginal  discharge  and  some  pelvic 
inflammation.  The  patient  improved  greatly  and  was  ready  to  leave  the 
hospital,  when  she  suddenly  dropped  dead  without  any  warning. 

Path.  No.  11044.  The  uterus  measures  approximately  8  x  9  x  10  cm. 
Tt  is  everywhere  covered  with  dense  adhesions.  Projecting  from  the  right  lateral 
wall,  l)Ut  intimately  connected  with  the  fundus  and  filling  the  uterine  cavity,  is 
a  necrotic  looking,  foul-smelling,  grayish-black  tumor  mass.  It  appears  to  be  a 
sloughing  submucous  myoma.  On  section,  it  is  grayish  or  reddish-black  in 
color  and  soft  in  consistency. 

At  one  or  two  points  small  interstitial  nodules  are  seen  scattered  throughout 
the  uterine  walls.  Accompanying  this  specimen  is  a  twisted  rope  of  tissue, 
about  three  feet  in  length,  grayish-black  in  color,  and  on  section  j)resenting  the 
same  apj)earance  as  the  necrotic  submucous  myoma. 

Histologic  Examination. — Sections  from  the  submucous  myoma  showed 
thtit  it  was  undergoing  necrosis  and  that  there  was  marked  su])puration.  A\  here 
the  tis.sue  was  preserved,  it  was  rather  cellular.  Blood-vessels  were  numerous 
and  markedly  engorged.  Cross-sections  of  the  vopr  of  tissue  showed  that  it 
likewise  consisted  of  myomatous  tissue.  In  most  places  it  had  undergone  al- 
most comj)lete  necrosis.  .\t  a  few  points  the  necrotic  muscle  showed  typical 
calcareous  de|)()sits. 

We  had  in  this  case  a  submucous  myoma,  which  had  in  part  imdergone  nec- 
rosis and  had  l)een  >:raduail\'  extruded,  formiiiii  a  tumor  thi'ee  feet  in  length. 


SX'BMUCOUS    .M  V(  ).MATA. 


Inversion  of  the  Uterus  Associated  with  Submucous  Myomata. 

In  our  series  of  uterine  myoniata  we  have  hatl  four  cases  in  which  partial  in- 
version of  the  uterus  was  noted  and  in  each  of  these  the  myoma  was  submucous. 
When  the  uterus  is  the  seat  of  a  single  tumor  which  l^ecomes  submucous  and 
pedunculated  and  is  being;  o-radually  extruded  into  the  vagina,  it  is  but  natural 
that  the  traction  of  the  ])edicle  on  the  uterine  wall  in  a  few  cases  will  produce 
partial  inversion  of  the  uterus. 

In  Case  1716  the  vagina  was  filled  with  a  round,  fii'ni  myomatous  tumor, 
about  11  cm.  in  diameter,  and  attached  in  the  uterine  cavity  by  a  pedicle  2.5  cm. 
in  diameter.     Bimanual  examination  revealed  a  slight  cupping  of  the  fundus. 

The  uterus  in  Case  7133  contained  a  submucous  myoma.  After  the  cervix 
had  been  split  and  the  tumor  di\-ided  into  foiu'  pieces  it  was  removed.  The 
uterus  was  partially  inverted  on  account  of  the  traction  of  the  myoma. 

A  smooth,  glistening,  pedunculated,  subnmcous  myoma  protruded  from  the 
enlarged  and  edematous  cervix  in  Case  1610;  at  the  site  of  the  fundus  was  a  cup- 
shaped  depression. 

In  Case  2873  the  patient  was  very  pale  and  had  a  very  ra])id  puls(\  A  sul)- 
mucous  myoma,  11  x  15  cm.,  protruded  fi'om  the  vulva.  It  was  attached  to  the 
uterus  by  a  pedicle  4.5  cm.  in  diameter.  The  fundus  was  nodular,  aljout  the 
size  of  that  of  a  three  months'  pregnancy,  and  partially  inverted. 

After  removal  of  the  submucous  growth  the  inversion,  as  a  rule,  can  be 
readily  rectified.  The  dangers  of  vaginal  myomectomy  or  vaginal  hysterectomy 
when  partial  inversion  exists  are  considered  on  page  575. 


CHAPTER  V. 

DILATATION  OF   THE   UTERINE   LYMPHATICS  ASSOCIATED 

WITH  MYOMATA. 

For  convenience  two  divisions  may  l)e  made:  (1)  Dilatation  of  the  snperficial 
lymphatics;   (2)  dilatation  of  the  deep  lymphatics. 

By  the  superficial  lymphatics  we  mean  those  that  are  so  near  the  surface  that 
they  are  readily  seen  as  soon  as  the  abdomen  is  o])ened.  Naturally,  the  condi- 
tion of  the  deej)  lym])hatics  cannot,  as  a  rule,  he  made  out  until  the  tumor  is 
studied  at  leisui'e  in   the   laboratory. 

Dilatation  of  the  Superficial  Lymphatics. 

In  the  chai)ter  on  Parasitic  Myomata  two  cases  are  mentioned  in  which  the 
omentum  furnished  abundant  nourishment  to  jxxlunculated  myomata,  and  large 
lymph-channels  coursed  down  the  omentum  to  the  tumors.  In  one  of  these 
cases  (Gyn.  No.  7220,  Fig.  18,  p.  22)  a  single  large,  tortuous,  thin-walled  lym- 
])hatic,  several  millimeters  in  diameter,  is  seen  passing  down  the  omentum  to 
the  tumor.  In  Case  8296  (Fig.  17,  p.  20)  several  large,  tortuous,  \)i\\v  lym- 
phatic vessels  are  seen  extending  down  from  the  omentum  to  the  tumor. 

Probably  one  of  tlie  most  striking  examples  of  a  large  lymphatic  coursing 
over  the  surface  of  a  myomatous  uterus  is  found  in  (lyn.  No.  13067  (Fig.  57). 
iMuerging  from  the  uterine  muscle,  several  centimeters  to  the  median  side  of  the 
uterine  horn,  is  a  markedly  lobulated  and  tortuous  lymjihatic  vessel.  This  in 
places  reaches  over  1  cm.  in  diameter  and  rises  nearly  1  cm.  from  the  surface  of 
the  uterus.  It  passes  downward  and  outward  between  the  tube  and  ovary  and 
is  lost  near  the  hilum  of  the  ovary.  Anterior  to  the  tube  is  a  much  dilated 
lymphatic  vessel. 

Another  remarkable  example  of  dilatation  of  the  lymphatics  is  furnished  by 
Gyn.  No.  11224  (Path.  No.  744Sj.  At  the  origin  of  the  Mt  tube,  between  the 
left  tube  and  ovary  and  between  the  tube  and  the  neighboring  round  ligament, 
were  cystic  spaces.  The}'  varied  from  1  to  2  cm.  in  diameter  and  their  nmscular 
covering  was  so  attenuated  that  their  clear  fhiid  contents  were  readily  seen. 
Some  of  the  spaces  on  section  were  found  to  be  made  up  of  numerous  smaller 
ones.  The  spaces  were  filled  with  serous  fluid.  In  sections  they  were  lined  in 
jtlaces  with  one  layer  of  flat  cells;  at  other  points  no  endothelial  lining  could  be 
detected.  Similar  spaces  were  present  in  the  vicinity  of  the  right  uterine  horn. 
In  neither  of  these  cases  were  there  adhesions,  which  sometimes  give  rise  to 
superficial,  subperitoneal  spaces — an  encysted  peritonitis. 


DILATATION    OF    THE    UTKKIXK    LY.MPHATICS. 


dilated       Ij/mpbat 


Fig.  57. — E.NonMois  Dilatation  ok  tiii.  I.-,  mimi  \tii>  on  tiii:  .SrHKAci;  oi  \  Mm>m\tois  I'tkuis.  (Nat.  !<ize.) 
Gyn.  No.  18067.  Path  No.  lOOTd.  iMiiciKiiiK  fnun  tin'  -iiif.uc  nf  ilir  ul<>ni>.  :i  fi-w  (•("iitiiiiotoi-s  aliove  ami 
anterior  to  the  left  tul)e,  i.s  a  tortuous  lymphatic  vcss.-l  uhi.h  \n  plioc-  i-  ..v.-r  1..'.  nu.  in  (iiamotor.  It  i)a.>*.>»e.s 
over  the  tube  down  hetwecti  tin-  lulic  ami  ovary  an. I  i-  lo~l  in  IIm>  .Icplh.  nc:ir  the  hiluni  ..f  111.-  ovary.  Thi." 
lymphatic  ve.s.sel  was  fille.l  with  clear  lluhl.  Antcrinr  to  the  lulic  i~  a  lar^'c  lynipliatic  vessi-l.  On  the  surface 
of  the  tube  are  a  few  .subperitoneal  si)accs.  Ihc  lunmr  i>  free  fn.ni  a.lli.'M..n>,  The  Kreal  increa.-e  in  size  of  the 
ovary  is  clue  in  a  large  meii-sure  to  dilated  l.\  niphaiic-.  in  p.iri.  in  iiian.\    c,\>ii<-  follicle-. 


74 


MVOMATA    OF    THE    ITHHl'S. 


Gyn.  No.  13067.     Path.  No.  10076. 
Enormous   dilatation    of    the    superficial    lymphatics 

a  n  (1    m  u  c  h     c  d  c  m  a    o  f    the     1  e  f  t     o  v  a  r  y  ,    a  s  s  o  c  i  a  t  e  d    wit  h 

a  111  >■  o  111  a  t  o  u  s     u  t  e  1'  u  s   {V\^.  57). 

S.  (;.,  white,  a.u'ed  t'oi1\--()iie,  inarried.     Admit te(l  .hily  9,  1906.     Operation. 

Hystei-omyoiiiectoiii}'.      The   specimen   consists  of   a  large  myomatous   uterus 

with  the  a])pendages  attached.  The 
uterus  is  soft  and  boggy,  and  on  sec- 
tion tlie  increase  in  size  is  found  to 
he  caused  by  a  large  degenerated  and 
cystic  myoma,  which  arises  from  the 
posterior  wall  and  is  partly  sul)mu- 
cous.  The  right  ovary  is  ap))arently 
normal.  The  left  ovary  measures  10 
cm.  ill  length,  is  correspondingly 
lii'oad,  and  very  soft  and  edematous. 
J'jiierging  fi'om  the  uterus  just  to  the 
anterior  and  inner  side  of  the  left 
uterine  hoi'ii  is  a  markedly  dilated 
and  superhcial  lymphatic,  which  in 
])]aces  reaches  nearly  2  cm.  in  di- 
ameter. It  passes  down  behind  the 
tube  and  is  lost  in  the  tissue  between 
it  and  the  ovary  (Fig.  57).  There 
are  also  dilated  lymphatics  l)etween 
the  left  tube  and  the  left  round  lig- 
ament. 

Microscopically,  the  uterine  mus- 
cle seems  normal,  l^ut  there  is  a  ten- 
dency for  the  glands  to  extend  into 
the  muscle.  The  tumor  itself  shows 
marked  hyaline  degeneration.  Sec- 
tions through  the  dilated  lymphatics 
that  were  seen  coiu'sing  ovei'  the  sur- 
face show  tliat  in  ])laces  they  have  a 
distinct  endotiielial  lining.  The  in- 
marked  dilatation  of  the  lymphatics. 
11a  noted  iiiacroscopically. 


Fig.  58. — Dilated  Lymphatic  Spaces  in  the  Uterine 
Wall  in  the  Neighborhood  ok  the  Right  Tube 
AND  Ovary,     (i  nat.  .size.) 

Gyn.  No.  11224.  Path.  No.  7448.  Covering  the 
surface  of  a  jjortion  of  the  right  tube  are  nuineroii?; 
subperitoneal  cysts.  .\t  the  cornu  is  a  raised  eystic 
area  extending  anteroposteriorly  a'  from  to  ii.  This,  on 
section,  was  found  to  be  made  \i]>  of  numerous  cystic 
spaces,  b  and  c  are  otlier  dilated  cystic  spaces  in  the 
uterine  wall.  .\ll  were  filled  with  clear  fluid.  In  many 
an  endothelial  lining  could  be  made  out. 

ci'ease  in  size  of  the  left    ovary  is  due  to 
These  have  given  rise  to  the  apparent  eilei 


Gyn,  No.  11224.     Path.  No.  7448. 

.\  ill  y  o  m  a  t  o  us  u  t  e  r  u  s  wit  h  m  a  r  k  e  d  d  i  1  a  t  a  t  i  o  n  o  f  t  h  e 
lymphatics  in  the  region  of  both  uterine  horns  ( l'"igs. 
58  and  59). 

C.    II.,    white,    agetl    forty-six.    married,     .\dinitted    April    25:    discharged 


DILATATION'    OF    THK    UTERIXK    LYMTHATirS. 


to 


May  22,  1904.  Hci-  family  history  is  not  ^(hhI.  Her  mother  (Hcd  in  (lial)etic 
coma;  a  })at('rnal  aunt  also  diet!  of  diabetes.  Her  father  died  of  cai'diac  asthma, 
one  brother  of  pericarditis,  another  brother  of  aneurysm,  and  a  paternal  aunt  of 
tuberculosis.  The  patient  has  been  married  twenty-six  years  and  has  had  two 
children,  twenty-four  and  twenty-one  years  old  respectively.  Ten  years  ago  she 
began  to  have  slight  bleeding  between  her  ])eriods.  This  has  gradually  increased. 
and  the  periods  have  also 
been  getting  longer  and  more 
profuse.  For  the  last  two  or 
three  years  she  has  had  con- 
siderable weakness,  and  has 
been  bleeding  almost  contin- 
uously. One  year  ago  her 
hemoglobin  was  58  per  cent. 

Operation.  Hysteromyo- 
mectomy.  The  highest  post- 
operative temperature  was 
102.2°,  on  the  fourth  day. 

Path.  No.  7448. 
The  specimen  consists  of  a 
roughly  spheric  myomatous 
uterus,  15  cm.  in  diameter. 
It  is  free  from  adhesions. 
The  uterine  cavity  is  much 
dilated.  Just  where  the  right 
tube  joins  the  uterus  is  an 
oval-shaped  swelling,  3  cm. 
X  1.5  cm.  (Fig.  58).  This  is 
lobulated,  covered  with  peri-      fk;.  so.— dilated  lymphatic  channki.s  at  thk  lkft  i  tkkink 

1  •  1       .1  -•  Horn    Bktween   the   Tube  and  Ovary    ani>   Between   the 

toneum  and  evidently  cystic.  .,.^,„,,  ^^^  i^„„.  ^^^,^„  i.,«ament.    c?  ..at.  size.) 

It    is    composed    of    numerous  C!yn.  No.  11224.     Path.  No.  7448.     At  the  uterine  horn  is  an 

,             ,,      ,                                   _  eloiiKate  cystic  dilatation,  the  anterior  an<l  posterior  confines  of  whirh 

SmOOtn-WalleCl     spaces,    vary-  ^j.^  indicated  by  a  and  (('.     This,  on  section,  was  found  to  be  coni- 

ino"  from   a   l^inh("ld   to    neaiiv  P"scd  of  numerous  smaller  spaces.     At  the  inner  end  of  the  utero- 

*^                  '     '      _  ovarian  ligament  is  another  cystic  space,  seen  at  /».     Between  the 

1       cm.       in      diameter.         T^he  tube  and  ovary  and  between  the  tube  and  round  liKamenl  are  other 

11                                            ,1  cystic  spaces   at     ■.     Soiiii'  of    ilu-iii   had     an   eiiiioihclial    liniiiK:   in 

walls  are  ai)parenl ly  com-  ^^^^^^^  .^  ^,^,,,,,,  ,_,„  ,,,.  _„^„,,.  ,„„  ,,,,..^  ^^,..,.^.  ,i„^..,  „•„,  ^.,,.,^,.  „„i,,. 
posed  of  muscle.     On  the  left 

side,  near  the  point  of  origin  of  the  left  tube,  there  is  a  moiv  diffuse  swelling 
(Fig.  59).  This  measures  4.5  x  2.5  cm.  and  pi-ojects  about  I  cm.  from  the  sur- 
face. On  section  it  also  pi-esents  a  honev-eonilxMl  ;i|ti>e;ii;inee.  between  the 
inner  cud  of  the  tube  and  the  utei'o-ovarian  ligament  is  an  o\al  cNst,  I  eiii.  in 
diametei'.  It  has  thin  walls  and  on  section  is  found  to  consist  of  two  main  cysts 
and  of  nuniei'ous  sniallei'  ones. 

On  examination  of  the  cystic  area  in  the  \-ieinit\-  of  the  left  uterine  horn  we 


76  MYOMATA    OF    TIIH    UTERUS. 

find  a  cross-section  of  the  tube  slightly  dilated.  The  uterine  muscle  sumnuiding 
this  is  perfectly  normal.  In  the  outlying  portion  the  tissue  is  very  edematous. 
The  large  spaces  in  places  show  no  definite  lining,  but  at  other  ])oints  have  one 
layei-  of  Hat  endothelium.  The  nuclei  of  the  endothelial  cells  are  s])indle-sha]ied. 
The  s|)aces  are  partially  (illed  with  a  homogeneous  material  and  take  the  eosin. 
We  aiv  uiuloubteilly  dealing  with  dilated  lymphatic  spaces. 

Sections  from  the  cystic  areas  near  the  left  utero-ovarian  ligament  and  from 
the  uterine  horn  on  the  right  side  show  a  similar  picture. 


Dilatation  of  the  Deep  Lymphatics. 

In  Gyn.  No.  3133  (Path.  No.  494)  the  uterus,  as  the  result  of  the  myomatous 
de\-elopment.  had  been  converted  into  a  pear-shaped  tumor,  36  x  32  x  32  cm. 
The  tumor,  on  section,  presented  a  pearly-white,  coarsely  striated  appearance 
and  had  scattered  throughout  it  homogeneous  areas,  l)rownish  in  color.  Mi- 
croscopically, the  uterine  muscle  itself  showed  much  hyaline  degeneration  and  in 
some  places  were  small  round  or  oval  empty  spaces  which  suggested  lymph- 
spaces.  Confirmatory  of  this  idea  were  many  channels  of  a  similar  shape,  filled 
with  hyaline  material  and  lined  with  endothelium.  Fully  half  of  the  large 
tumor  had  undergone  hyaline  degeneration,  but  there  was  no  breaking  down  of  the 
tumor  substance.  Its  blood-supply  was  very  ])oor.  Surrounding  nearly  every 
blood-vessel  were  round  or  oval  spaces,  similar  to  those  seen  in  the  uterine  mu.^^cle. 
These,  from  their  arrangement,  looked  like  lymph-si)aces. 

The  lymph-s])aces  in  the  uterus  in  Case  4203  were  markedly  dilated.  The 
uterus  was  9  cm.  in  diameter  and  very  soft. 

In  Gyn.  No.  3113  (Path.  No.  4S7)  the  uterus  had  been  converted  into  a  multi- 
nodular myomatous  tumor,  approximately  25  cm.  in  diameter.  Large  and  small 
smooth-walled  sinu.ses  were  scattered  everywhere  throughout  the  myomatous 
tissue.  The  largest  of  these  was  1.2  cm.  in  diameter.  Many  of  the  larger  com- 
municated with  the  smaller  ones.  Most  of  them  were  filh^d  with  serous  fluid  and 
a  few  contained  blood.  On  histologic  examination  the  myomata  showed  much 
hyaline  degeneration  and  some  edema.  The  large  sinuses  that  apj^eared  to  lie 
lyiii])li-channels  in  many  places  showed  an  endothelial  lining:  at  other  points  no 
lining  could  be  detected.  As  the  blood  in  the  arteries  and  veins  had  been  well 
preserved  in  Mueller's  fluid  and  as  these  spaces  were  comparatively  free  from 
blood,  we  are  inclined  to  believe  that  they  were  lymph-\essels. 

Unless  careful  histologic  examinations  luv  made  one  can  never  be  sure  that 
such  spaces  are  lymphatics,  as  the  majority  of  clear  spaces  found  in  myomata 
result  from  the  melting  away  of  the  tissue  following  hyaline  degeneration.  This 
(luestion  is  discussed  fully  in  the  chapter  dealing  with  hyaline  changes  in  uterine 
myomata  (see  p.  92). 


CHAPTER  VI. 
TORSION  OF  THE  UTERUS. 

Torsion  of  the  uterus  is  occasionally  met  with  in  niyonia  cases.  It  may,  for 
convenience,  be  divided  into — (1)  torsion  of  the  cervix;  (2)  torsion  of  the  body 
of  the  uterus;  and  in  addition  we  may  have  twisting  of  a  |)eduncu]ate(l  sub- 
peritoneal myoma. 


TORSION  OF  THE  CERVIX. 

In  Case  4925  we  have  an  excellent  example  of  tor 
globular  myomatous  uterus  reached  to  within  8  cm. 
free  from  adhesions,  but  had  rotated 
through  an  angle  of  90  degrees  to  the 
right.  The  left  round  ligament,  tube, 
and  ovary,  therefore,  lay  in  front  (Fig. 
60).  On  referring  to  Fig.  61,  it  will  l)e 
noted  that  the  upper  ])art  of  the  cervix 
had  been  greatly  thinned  out.  A\'hether 
this  was  the  cause  or  the  effect  of  the 
torsion  it  is  impossible  to  accurately 
determine,  but  as  the  cervix  w^as  evi- 
dently put  on  the  stretch  by  the  ever- 
increasing  upward  growth  of  the  tumor, 
there  has,  in  all  probability,  been  atro- 
l)hy  of  the  cervix,  facilitating  the  tor- 
sion. 


si  on  of 
of  the 


the  cerv 
xiphoid. 


ix.     The 
It  was 


\) 


Torsion  of  the  Body  of  the  Uterus  in 
Cases  of  Uterine  Myomata. 

As  this  condition  is  coniparativcly 
rare,  a  brief  description  of  the  eight  in- 
stances in  our  series  may  be  of  intci-cst. 

In  Case  3.'^7  the  lower  abdomen  was 
filled  with  a  niuhinodular  myomatous 
uterus.     The  uterus  was  twisted  on   its 


I'k;.  CpO.  -Rotation  of  a  Myomatoi's  Utkhts  on 
ITS  Ckuvix. 
(ijii.  No.  4012.5.  'I'lie  )(l<>ljular  inynmaliiiis  \ilonis 
is  perfectly  .smootli,  l)Ut  has  rotufcd  tlirmiKli  an  aiiulo 
of  !)0  ileRrees  (o  the  riRht.  The  riRlit  appeiKiiiKos 
liavc  l)fe II  carried  l)ack\varii;  tlie  left  loiliul  liKaiiieiit, 
tiilie,  and  ovary  lie  just  above  the  l)ladder.  For  tlie 
unfol<led  cervix  see  Vir.  i\\ .  A  myoma,  12  x  21  x  27 
cm.,  was  reinoveil  per  iihdoriiiti.  For  the  .sul)se(|uent 
development  of  other  myomata  see  Fig.  331,  p.  562. 
lAfl.T  Howard   A.   Kelly.) 

axis. 

The  irregularly  globular  inyoinatous  uterus  in  Case  V.\\\  was  as  large  as  that 
of  a  six  and  one  half  months"  |)regnan('y.      it  was  twisted  through  an  angle  of  90 


78 


.MYO.MATA    OF    THE    UTKRUS. 


degrees  from  left  to  right  and  the  left  ovary  eontaiiicd  a  unilocular  cyst  8  cm, 
in  (lianictcr. 

In  Case  ")()44  a  myoma,  12  x  12  cm.,  occupied  the  posterior  uterine  wall. 
Tlici'c  was  torsion  of  the  uterus  through  an  angle  of  90  degrees  fi'oin  i-ight  to  left. 

Tile  niyoinalous  uterus  in  Case  5784  filled  the  entire  abdomen.  The  omentum 
was  firmly  attached  to  the  tumor  over  its  entire  breadth  and  furnished  enor- 
mous vessels  to  the  myoma.  The  uterus  had  rotated  through  an  angle  of  180 
degrees  from  right  to  left. 

The  abdomen  in  Case  5946  was  filled 
with  a  synunetric  and  semifluctuant 
myomatous  tumoi".     The  uterus  had  ro-  y^ 

tated  90  degrees. 

In  Case  6570  the  myomatous  uterus 
reaelie(l  the  umbilicus.     Its  pedicle  con- 


,41/ 


\Rrlig. 


Fig.  61. — Atrophy  of  the  Cervix  Associated  with  a 
Large  Globiti.ar  Myomatous  Uterus. 
Oyn.  No.  4925.  riie  ui)i)er  i)art  of  the  cerv'i.x  is 
greatly  attenuated,  and  at  uperatidn  the  iiteru.s  was 
rotated  to  the  right,  giving  the  iiictuie  seen  in  Fig.  60. 
(After  Howard  A.  Kelly.) 


Fic.  62. — Marked   Torsion    of   a    Myomatous 
Uterus. 

(i.\M.  No.  fi.570.  The  great  enlargement  in 
the  iiiJiKT  i)ait  of  the  uterus  was  caused  by  a 
.spheric  myoma.  Near  the  middle  of  the  uterus 
proper  there  is  marked  torsion  from  right  to 
left — so  much  so  that  the  insertion  of  the  right 
round  ligament  is  carried  to  the  o|)posite  side, 
while  the  right  tube  and  ovary  lie  in  the  median 
line.  .\t  the  i)oint  of  the  twist  the  diameter  of 
the  uterus  had  been  reduced  to  1  cm. 


sisted  of  the  middle  ixjilion  of  the  uter- 
us. Here  there  was  a  definite  twist  from 
right  to  left.     The  ])ortion  of  the  uterus 

forming    the  jx'dicle    had   become  markedly   attenuated,    being   only    1    cm.   in 
thickness  (Fig.  ()2). 

Tn  Case  7()9")  the  myomatous  uterus  reat 
made  a  (|uarter  turn  from  left  to  right,  tin 
The  twist  was  near  the  cervix. 

In    Case    1 1()()7    the   alxlomen    was   syn 
been  definite  torsion  of  the  uterus  from  left  t 


•lied  the  umbilicus.     The  cervix  had 
■  left   tube  and  ovary  lying  in  front. 

nmetrically    distended.     There    had 
to  right  (Fig.  68j. 


TORSION'    OF    THE    ITHHUS. 


rg 


In  none  of  these  cases  had  the  torsion  <iiveii  rise  to  any  especial  clinical 
symptoms.  A\'hile  it  is  impossible  to  tell  definilely  why  ttjrsion  took  place,  it 
seems  probable  that  the  twisting  commenced  as  a  result  of  the  attempts  of  the 
tumor  to  accommodate  itself  to  its  surroundings.  When  once  twisting  starts 
it  often,  for  some  unknown  reason,  tends  to  increase  in  degree. 

Torsion  of  the  Uterus  with  Complete  Severance  of  the  Body  from  the  Cervix. 

Professor  Raffaele  Bastianelli,  of  Rome,  when  in  J^altimore,  related  a  most 

interesting  cas(>  of  this  character  that  had  come  under  his  observation,  and  on 


Fig.  63. — Torsio."<  of  a  Large  Globular   Myomatous  Utkuis. 
Gyn.  No.  11067.     Path.  No.  7285.     There  is  marked  tor.sion  of  the  uterus  from  left  to  rinht,  so  that  the  in- 
sertions of  the  left  tube  and  ovary  lie  in  front.     The  lower  surface  of  the  left  ovary  has  hecomc  lirndy  plasleriNl 
on  to  the  surface    of  the    myomatous    uterus.     The    blood-vessels  lyiriK  between   Ihi-    tube   and  ovary  are  much 
dilated. 

his  return  to  Italy  he  scnl  us  an  explaiialor}-  ilhisl  ration  ( !'"ig.  (Ih.  in  llie 
beginning  there  was  evidciilly  loi'sion  of  the  utci-us.  This  grailu.-iily  became 
more  marked  until  fiiiall\-  tlie  fundus  was  comiilelelN-  se\-ere(j  Iroiii  llie  eei-xix. 

Miss  E.  J.  C,  aged  lifty-lhive,  seen  !)>•  Dr.  HasliatieHi  in  iJoiiie  in  I'.KIl*. 
The  patient  menstrualed  last  eiglil  years  piv\iously.  i'or  mtnv  iliaii  tweiily- 
one  yeai's  a  lumor  has  been  iiolieecj  in  I  he  lower  abdomen.  Tliis  at  lirsl  was  not 
painful,  but    in    bSSl.j'or  one   da>-,  she  li;id  sexciv    pain    throughout    the   entire 


so 


.MYOMATA    OF    THK    ITKIU'S. 


abdomen.  In  1890  she  had  what  was  siij)j)os(>d  to  be  a  severe  attack  of  ])eri- 
toniti.s,  wliieh  histed  more  than  eifjht  days  ami  was  accompanied  with  nuxh'rate 
fever.  Tn  ISOo  slic  had  another  attack,  and  two  or  three  others  at  hiter 
intervals.  In  l'.)01,  after  exercise,  she  had  severe  abdominal  pain  for  three 
days  and  since  then,  on  mnnerous  occasions,  has  had  much  abdominal  discom- 
fort after  exercise.  In  March,  1902,  she  had  sudden  ])ain  duriiiii;  the  night. 
There  was  little  vomiting,  some  diarrhea,  and  abdominal  distention.  She  was 
in  bed  for  a  month  and  suffered  a  good  deal.  From  that  time  until  the  day 
of  opi'ration  she  has  had  numerous  other  attacks  of  abdominal  ])ain. 

May  25,  1902:   Occupying  the  lower  al)domen.  and  extending  almost  to  the 
umbilicus,  is  a  tumor  about  the  size  of  a  child's  head,  hard,  immovable,  rather 


Fig.  64. —  Sfoxtaxkous  A.mpltatiox  of  a  Myomatous  Uterus,    (i  nat.  si7e.) 

niustration  sent  by  Professor  R.  Bastianelli,  of  Rome.     To  the  riaht  is  a  large  myoma  which  had  grown  fa.st 

to  the  abdominal  wall.     Toward   the  left  is  the  small   uterine  cavity,  which  has  been  opened.     At   n  is  a  twisted 

pedicle  consisting  of  the  broad  ligament,  round  ligament,  and  the  tubes  and  ovaries  much  atrophied,     c  is  the 

fimbriated  end  of  one  of  the  tubes.     The  torsion  had  resulted  in  complete  separation  of  the  uterus  from  the  cervix. 

painful,  and  .situated  somewhat  to  th(>  left.  On  n-ctal  examination  the  cervix  is 
easily  felt.     Xo  connection  can  he  made  out  i)etween  the  tumor  and  the  cervix. 

May  26:  On  section  of  the  ahiloinen  a  myoma  was  found.  This  was  round, 
adherent  to  the  abdominal  wall  on  the  left  side,  and  was  se})arated  with  diffi- 
culty. The  tumor  was  then  freely  movable,  and  was  found  to  be  attached  to 
the  Hoor  of  the  right  iliac  fossa  by  a  large  pedicle.  This  was  cut  between  clamps 
and  the  tumor  then  lay  perfectly  free  in  the  hands  of  the  operator. 

The  specimen  consists  of  the  body  of  the  uterus,  with  a  round  myoma  attached 
to  its  anterior  wall,  and  also  includes  l:)oth  ovaries  and  tubes  and  round  ligaments 
twisted  many  times.  In  the  jMcture  (Fig.  64)  one  can  see  easily  the  cavity  of 
the  uterus  which  has  been  opene(l.  It  is  small  and  has  an  atrophic  mucosa.  It 
ends  in  the  twisted  pedicle.     Attached  to  the  uterus  are  the  tubes  and  ovaries. 


TORSION  OF  THE  UTKKUS. 


81 


Professor  Bastiaiielli  ^ivcs  the  following  explanation  of  the  condition.  The 
body  of  the  uterus  was  twisted  first,  and  little  by  little  completely  severed  from 
the  cervix.  Then  the  tubes  and  broad  ligaments  became  twisted,  and  finally 
the  tumor  became  adherent  to  the  abdominal  wall.  The  condition,  then,  rep- 
resents a  spontaneous  sui)ravaginal  amputation  of  the  uterus,  with  secondary 
twisting  of  the  tubes  and  the  ligaments.  Professor  Bastianelli  thinks  that  if 
the  uterus  had  not  been  removed  the  twisting  of  the  tubes  and  ligaments  could 
have  advanced  still  further.  The  uterus  would  then  have  been  completely 
separated  from  them,  and  would  have  remained  attached  to  the  ])arietal  peri- 
toneum like  a  parasitic  myoma. 


Fig.  65. — Torsion  of  a  Subperitonkal  Pedunculated  Myoma.     (J  nat.  size.) 
C.  H.  I.  (C),  August  12,  1902.     The  specimen  consists  of  an  irregular,  fan-shaped,  subperitoneal  petluiiculate*! 
myoma.     At  the  pedicle  the  tumor  has  twisted  from  right  to  left.     Near  the  center  of  the  tumor  many  vessels 
are  ramifying  over  its  surface. 


Torsion  of  Subperitoneal  Myomata. — In  Case  ('.  the  ])atient  was  admitted  to 
the  Church  Home  and  Infirmary  Augnst  12,  1002.  She  had  a  small  multinodnlar 
uterus  and  a  large  subperitoneal  pedunculated  nodule,  which  had  become  twisted 
through  an  angle  of  90  degrees  from  right  to  left  ( h'ig.  (>,'))  and  was  densely  ad- 
herent to  the  tissues  at  the  jx-lvic  brim.  The  |)ediclc  was  se\eivd.  ami  the  ad- 
hesions dealt  with  from  the  under  side.     The  uterus  was  then  reinoxed. 

In  Case  127(H),  a  colored  woman,  aged  forty-two.  had  (•oiiii)lai!ied  of  sudden 
cramp-like  pains  in  the  right  lower  abdomen  six  da>s  bcl'oiv.  Tliere  was  markeil 
dysuria  and  a  moderate  elevation  in  leiii|)ei-ature. 

On  her  admission  to  the  hos|)ital  \)v.  II.  T.  llutchins  found  the  lower  abdo- 
men tender  and  detected  an  indefinite  mass  in  the  left  iliac  fossa.  There  was  a 
(i 


82 


MYOMATA    OF   TUE    UTKRUS. 


niodcratt'  IcukoiTlical  dischariic.  The  cervix  was  low  down,  and  the  uterus  in 
antt'-i)ositi()n  and  fixed.  On  both  sides  were  wliat  appeared  to  l)e  definite  tubo- 
ovarian  masses,  wiiich  were  tender. 

When  tile  abdomen  was  opened  a  myoma,  4.')  x  5  x  S  em.,  immeiliately  })re- 
scnted.  Tliis  was  ])ednneulate(l,  and  had  made  one  (•omi)lete  twist,  so  tiiat  the 
blood-sui)piy  had  been  entirely  shut  off  (Fig.  (H)).     The  tumor  was  of  a  dark, 


Fig.  66. — Suddkn  Torsion  of  a  Sibperitoxkal  I'lcinNcuLATKi)  Myoma  with  Complete  Shl'ttino  pKF  of  its 

Blood-supply, 

Gyn.  No.  12709.  I'ath.  No.  9.545.  The  utenis  was  relatively  iioniial  in  size.  The  right  appeiulases  were 
densely  adherent.     The  left  tube  was  dilated,  as  seen  in  the  drawing,  and  the  ovary  contained  a  cyst. 

.Attached  to  the  funihLs  is  a  subperitoneal  pedunculated  myoma.  This  is  very  dark  in  color,  and  its  vessels 
are  much  ililated,  owing  to  one  complete  turn  of  the  myoma  on  its  pedicle.     The  twist  is  clearly  seen  at  a. 

reddish-green  color,  hut  had  not  as  yet  undergone^  necrosis.  The  omentum  was 
lightly  adherent  over  its  surface.  The  right  apiK'iidages  were  densely  adherent. 
The  left  ovary  contained  a  cyst,  7  cm.  in  diameter. 

The  uterus  was  removed  and  the  cyst  evacuated.  The  tem])erature  reached 
102°  F.  on  the  second  day.  but  recovery  was  speedy. 

Pat  h  .  X  o  .  1) .')  4  .")  .  Sections  from  the  tumor  sliowed  that  the  blood- 
vessels just  beneath  the  capsule  of  the  st rangulat eil  subiKiitoneal  myoma  were 
very  much  dilated  and  the  myomatous  tissue  itself  had  undergone  slight  cystic 
change.  Had  this  patient  not  been  ])rom])tly  ojierated  u])oii  gangrene  of  the 
strangulated  tumor  would  have  soon  taken  |)lace  ;md  ])eritonitis  followed. 

Torsion  of  the  pedicle  was  also  noted  in  Cases  4485  and  7220. 


CHAPTER  MI. 
HYALINE    AND    CYSTIC    DEGENERATION. 

Hyaline  Degeneration  of  Uterine  Myomata. 

The  majority  of  myomata  show  cithcu-  gross  or  histologic  pictures  indicative 
of  hyahne  degeneration.  In  order  to  exchide  absohitely  the  presence  of  h3'ahne 
changes  it  is,  of  course,  necessary  to  carcfuhy  cut  each  myoma  and  also  to 
make  slides  from  innumerable  portions  of  each  tumor.  In  our  consideration  of 
the  sul)ject  we  have  dt>alt  with  only  those  tumors  in  which  the  degeneration  was 
readily  recognized.  In  114  of  our  cas(>s  early  or  advanced  changes  were  easily 
detected.* 

A  thorough  knowledge  of  the  early  literature  on  the  subject  can  be  obtained 
from  a  study  of  the  comprehensive  article  on  Fibromata  and  Cystofibromata  of 
the  Ovary  by  H.  C.  Coe.f  Although  published  more  than  twenty-five  years 
ago,  it  deals  with  the  subject  of  degeneration  of  solid  ovarian  and  uterine  tumors 
in  a  clear  and  succinct  manner  and  is  written  in  a  very  attractive  style. 

A  careful  study  of  the  subject  has  led  us  to  classify  hyaline  degeneration  of 
uterine  myomata  according  to  the  following  stages: 

*  List  of  Cases  or  Hyaline  and  Cystic  Myomata. 


Gyn.  No. 

Gyn.  No. 

Gyn.  No. 

Gyn.  No. 

659 

3345 

4193 

11806 

San.  1682 

1628 

3349 

4293 

11944 

1672 

3385 

4415 

11984 

San.  1868 

1909 

3394 

4441 

11989 

San.  1924 

2606 

3408 

4485 

12139 

San.  1925 

2672 

3437 

4635 

121S5 

San.  1973 

2691 

3440 

4828 

12225 

F.  Auji.  10.  1902. 

2699 

3445 

4869 

12234 

C.  H.  I.  620 

2718 

3449 

4894 

12423 

C.  H.  I.  (i64 

2746 

3461 

5021 

12439 

C.  H.  I.  7!)(i 

2772 

3475 

5058 

12453 

C.  11.  I.  1019 

2777 

3485 

5141 

12488 

C.  11.  I.  129() 

2852 

348S 

5325 

12522 

2881 

3491 

5766 

12591 

3038 

3493 

6002 

12696 

3066 

349S 

6272 

1273S 

3107 

3504^ 

6432 

1 2779 

3113 

3552' 

7049 

I2S39 

3130 

3522 

7220 

12SH 

3199 

3661 

7511 

12SI!) 

3216 

12S<il 

3218 

3SS2 

8882 

rjS77 

3232 

3960 

((0.30 

13123 

3971 

•)l  IS 

1.3625 

3296 

3991 

•t'.i-'l 

II.  A.  K.  I'd).  22, 

,  1S96. 

3320 

lOl.^N 

S:in.  '.Ml 

3338 

1 1  7-' 

1  1  ll'.l 

Sail.  Kll  1 

Hm.I  all 

of  our  fascs  Ik'cii  ( 

•aiclully  cxainiiicd. 

the  huiiiIk  T  WKiild  1 

Ki\c  liccii  matcri.-illy  in 

creased. 

t  AnifT. 

Jour,  of  ( >l>st ('tries. 

ISS'J.  vol.  \V.  J).  5 
S3 

61. 

84 


MYOMATA    OF    THK    ITKRUS. 


1.  Early  hyaline  changes  recognizable  only  with  the  microscope. 

2.  Hyaline  areas  recognizable  macroscopically. 

'A.  Advanced  hyaline  degeneration  with  liquefaction  and  the  i'orniation  of 
small  cysts. 

4.  Hyaline  degeneration  with  the  formation  of  large  cysts  in  the  myomata. 
Naturally  one  stage  gradually  merges  into  the  succeeding  one. 


c 

Fig.  67. — Abrupt  Transformation-  of  Myomatous  into  Hyaline  Tissue.  (X210  diameters.) 
Gyn.  No.  3107.  Path.  No.  472.  In  the  left  upper  corner  at  a  is  typical  myomatous  tissue,  but  the  greater 
part  of  the  field,  as  indicated  by  b,  has  undergone  hyaline  degeneration.  This  can  be  termed  massive  hyaline 
degeneration,  the  muscle  fibers  ending  abruptly  and  being  almost  entirely  replaced  by  hyaline  tissue.  In  a  few  jjlaces 
colorless  Hhers  of  connective  tissue  aie  still  in  evidence.  The  majority  of  the  free  cells,  as  indicated  by  r,  belong  to 
the  endotheUum  of  the  delicate  capillaries.     .\  few  polymorphonuclear  leukocytes  are  seen  in  the  hyaline  material. 


Early  Hyaline  Changes  Recognizable  only  with  the  Microscope.* — Only  rarely 
have  we  made  a  thorough  examination  of  a  myoma  without  finding  areas  of 
hyaline  changes.  This  degeneration  is  most  easily  recognized  when  the  specimen 
is  stained  with  hematoxylin  and  eosin.  The  hyaline  tissue  takes  the  co.'^in  stain, 
and  is  usually  recognized  as  a  homogeneous  tissue  devoid  of  nuclei.  The  degenera- 
tion may  be  scattered  in  patches  throughout  the  field,  but  is  generally  sharply 

*  The  following  cases  showed  early  histologic  changes:  2606,  2672,  2691,  2699,  2746,  3107, 
3218,  3338,  .3385,  3408,  3437,  3493,  3552,  4441,  6002,  11984,  12139,  12185,  12225,  12423,  12439, 
124.-)3,  and  12849. 


HYALINE    AND    CYSTIC    DEGEXEKATIOX.  85 

circumscribed,  as  is  well  seen  in  Fig.  67.  Here  the  muscle  ends  abruptly  and  is 
rei)laced  by  hyaline  tissue,  with  here  and  there  a  muscle-fiber  or  an  endothelial 
cell  of  a  capillary  still  jK'rsisting.  In  other  sections  little  masses  of  muscle- 
fibers  still  survive  as  islands  in  the  sea  of  hyaline  tissue.  This  was  noted  in 
Cases  2772  and  3349.  Although  the  hyaline  degeneration  occurs  frequently  en 
masse,  it  may  show  a  predilection  for  the  muscle-bundles,  as  in  Fig.  68.  In  this 
picture,  although  the  stroma  between  the  muscle-bundles  shows  hyaline  degener- 
ation,  the    muscle-bundles    themselves    show    the    most    striking   change,   one 


a  trr 


a 

Fig.  68. — Focal  Hyaline  Degeneration  in  Muscle-bundle.s.  (X120  diam.) 
Cyn.  No.  6002.  Path.  No.  2275.  The  tumor  was  a  submucous  myoma  about  11  cm.  in  diameter.  One  is 
instantly  impressed  with  the  small,  delicate,  discrete  areas  of  hyaline  degeneration  indicated  liy  a,  it.  This  is  par- 
ticularly well  seen  in  the  muscle-bundle  indicated  by  b,  nearly  half  of  which  has  l)een  converted  into  hyaline  ma- 
terial. The  fibrous  stroma  (c)  has  also  undergone  some  hyaline  change.  Such  a  distribution  of  the  hyaline  de- 
generation is  most  unusual. 

bundle  containing  at  least  five  or  si.\  large  foci  of  hyaline  degeneration.  The 
picture  presented  in  P'ig.  68  is  a  most  unusual  one. 

The  blood-supply  in  the  hynliiic  area  is  usnall>-  \cry  liinitrd.  but  the  sur- 
rounding ti.ssue  is  often  liberally  studded  with  blood-vessels  :iiid  occasionally 
there  have  been  hemorrhages  into  the  degenerated  tissue. 

In  a  few  cases,  as  in  (Jyn.  Nos.  2772,  3()(;(').  :521(),  12S77.  San.  \o.  P.L'.").  ('.  II.  I. 
No.  1019,  the  hvaline  degenernt  ion  is  \i'i-y  pi-oiuiunced  ;ii-()U1h1  ihe  Mdod-x-essels. 
The  vessels  are  usually  small  and,  as  shown  in  I'ig.  (•'.»,  the  eiidot  lu'liuni  of  the 
capillary  still  i)er.sists,  but  the  \-essel-\v;ills  ;ind  the  suiToiinding  tissue  have  been 


86 


MYO.MATA    OK    TIIK  UTKHUS. 


entirely  eonveiled  into  hyaline  inalefial.     In  only  two  cases  (Nos.  3445  and 
3488)  (lid  we  find  any  small-round-eelled  infill  I'ation. 

Hyaline  Areas  Recognized  Macroscopically. —  Tsually  such  changes  are 
not  detecteil  until  the  specimen  has  been  cut  o])en.  'i'hey  may  occur  in  sub- 
peritoneal, interstitial,  or  submucous  myomata,  and  may  be  limited  to  one 
nodule  or  be  ])resent  simultaneously  in  several  myomata. 

Necrosis      was     noted 
d 


,y^ 


^ 

■i*? 


niacrosc()i)ically  in  cases 
2881,  3199,  3296,  3991, 
7511,  11461,  and  12738. 

Some  of  the  tumors, 
on  palpation,  are  firm  and 
differ  in  no  \\ay  from  an 
ordinary  myoma.  Others 
are  soft  and  succulent  and 
occasionally  the  tumor 
may  give  a  soft,  elusive 
feel,  suggesting  a  lipoma, 
as  was  the  case  in  No. 
3294. 

On  cross-section  the 
area  of  degeneration  is 
usually  sharply  defined 
and  is  whitish  yellow  in 
color.  In  such  an  area 
the  muscle  st nation  is  usu- 
ally still  clearly  recogniz- 
al)le.     In  Fig.  70  we  have 

Gyn.  No.  .3216.  Path.  No.  5.34.  At  a  is  the  typical  myomatous  '^  "^  ^'O'  gOOd  exaini)le  Ot 
tissue.  6,  h,  b  are  transverse  and  longitudinal  sections  of  blood-vessels  tllC  sliarp  differentiation 
surrounded  by  a  broad  zone  of  hyaline  material.  All  that  remains  of  the 
normal  vessel-wall  is  the  endothelial  lining.  At  c  the  myomatous 
tissue  has  imdergone  complete  hyaline  degeneration.  The  upper  jiart 
(if  the  field  has  been  converted  almost  entirely  into  hyaline  tissue. 
The  muscle-fibers  that  remain  are  gatheretl  into  little  bunches  that 
stain  very  deeply  at  d,  d,  d.  They  are  being  gradually  crushed  out  of 
existence,  owing  to  pressure  exerted  by  a  rapidly  enlarging  abscess  in 
the  center  of  the  myoma. 


\iw-  'v-  "**?■    *^     W  i 


.r.tf/- 


mM^A 


-^^j 


Fi< 


69. — Makkki)  Hyaline   Degeneration  of  the  Walls  of  the 
Blood-vessels   in   a   Myoma.     (X65   diam.) 


from  the  surrounding  my- 
omatous tissue.  The  cen- 
ter has  undergone  de- 
generation. The  fibrous 
arrangement,  although 
somewhat  alteix^d,  is  still 
recognized,  and  in  this  case  the  degenerated  area  is  separated  from  the  sur- 
rounding myomatous  tissue  by  a  zone  of  hyaline  tissue  from  which  all  trace  of 
the  fillers  has  disappeared.  Fig.  73  (p.  93)  represents  the  extreme  hyaline 
degeneration  that  may  occur  in  a  .subperitoneal  myoma.  Fully  three-(iuarters 
of  the  tumor  has  undergone  hyaline  transformation  and  the  junction  between 
the  unaltered  myomatous  tissue  and  the  ai-ea  of  degeneration  could  hardly  be 
sharjH'r.     The  area  of  degeneration  is  in  the  i)art  furthest  from  the  bIood-su])ply. 


HYALIXK    AM)    CYSTIC    DEGKXKRATION. 


87 


The  area  of  hyaline  degeneration  is  usually  whitish  yellow  in  color,  but  oc- 
casionally we  have  seen  it  yellow. — bright  yellow  suggesting  fat, — grayish  blue, 
grayish  red,  yellowish  l)r()wn,  pink,  dark  red.  or  a  reddish  blue. 

Histologic  examination  shows  that  the  hyaline  areas  are  almost  totally  devoid 
of  cell  elements.     Here  and  there,  however,  a  few  muscle-fibers  are  still  present. 


Polyp 


Polyp 


Fk;.  70.— Hyaline  Degenkration  in  the  Center  ok  an  Interstitial  Myoma.     (8  nat. 

San.  No.  941.     I'ath.  No.  411.3.     The  uterine  cavity  is  con.si(leral>l.v  clonKated;  .situate.1  in 

cervix  are  polypi.     Occupying  the  anterior  wall  is  an  interstitial  myoma  aix.ut   1.5  cm.  in  <liamot 

of  this  (a)  has  partially  disintegrated.     Separating  this  degenerated  area  fnim  the  ordinary  myom 

ribbon   of  h.\;iliiie  material   (b). 


size.) 

the  funtlus 
er.  The  ce 
alous  li.>isiH' 


tiler 
is  a 


The  l)right  yellow  areas,  as  a  rule,  represent  a  simple  liy.-iline  degeiienition.  but 
occasionally  the  color  is  due  to  the  large  deposit  of  yellow  pigment,  the  result  of 
old  hemorrhage. 

Where  the  areas  are  dark  in  coloi',  vniying  amounts  of  eoagulaiion  neei-osis 
are  usually  present.     Here  the  tissue  has  undergone  complete  death.     The  out- 


88 


.MVOMATA    OF    THK    ITKIU'S. 


lines  of  the  iiiusclc-fihcrs  and  of  the  iiitci'vcning  connective  tissue  still  ])(Tsist. 
The  stain  with  hematoxylin  and  eosin  is  faint  and  rather  indistinct  and  frag- 
ments of  nuclei  are  found.  In  a  few  instances  a  slight  degree  of  infiltration  with 
polyinoi'phomiclear  leukocytes  can  be  noted. 

Advanced   Hyaline    Degeneration   with    Liquefaction   and   the   Formation   of 
Small  Cysts. — The  gradual  merging  of  the  hyaline  myomatous  tissue  ])resents 

the  most  delicate  and 
beautiful  macrosco])ic  and 
microscopic  pictures  and 
is  readily  followed  in  nearly 
all  the  cases  in  which  the 
myoniata    contain    cystic 


i*'^.'     I    S^-*^*K"      •  .• — ••^---^^- 


...  ..-^s^v 


.  '^-s.- 

:'j'^^ 


de- 

in 

iefly 

in 

■esent. 

On  palpation  such  a  uterus, 
after  its  removal,  often 
gives  a  sensation  as  if  it 
were  Huctuant  or  semi- 
fluctuant  and  at  times  is 
so  soft  that  the  patholo- 
gist may  suspect  a  preg- 
nancy if  the  uterus  is 
symmetrically  enlarged. 
So  suspicious  have  we  been 
on  several  occasions  that 
we  hesitated  to  cut  into 
the  sjH'cimen   fearing  that 


Fig.   71. — Edkma  ok  a   Myoma.     (X   120  diam.) 
Gyn.  No.  11989.     Path.  No.  8445.     The  entire  picture  presents  a 
loose  appearance,  in  contrast  to  the  compactness  of  an  ordinary  my- 
oma.    At  a  is  a  cross-section  of  a -swollen  muscle-fiber.     At  fe  is  a  fiber        the     OjX'ratol"    had    by    UllS- 
that  has  imbibed  considerable  fluid  and  the  nucleus  ha.s  been  pushed  *"        ,     1  .  .1  .         i 

the  side  of  the  cell.     .\t  c  are    two    muscle-fibers    which  have    appar-        take      I'einOVeU      a      UOrmal 
cntly  lost  their  nuclei.     In  the  transverse  sections  the  swollen  muscle-        nre^i'liailt    Utcl'llS 
fibers   bear  a  striking    resemblance  to  the    e.xfoliated   tubal    epithelium 

found  in  a  hydrosalpinx.     The  apparently  emiity  spaces  are  filled  with  Oil  SCCtlOll,   tllC   lliyoma 

a  serum  of  sufficient  density  to  coagulate  en  masse  instead  of  becoming  rrivnif  ^  tVir>  11  'ii'il     'ii-ii^ri'if 

granular.  1        '  '  ^^     c       '  1  J     "^ 

ance,  save  for  the  fact  that 
it  is  very  juicy  and  from  the  cut  surface  much  serum  runs  off.  This  edema  is 
u.'^ually  associated  with  hyaline  degeneration,  but  may  occur  at  points  where 
none  exists. 

Histologically,  the  usual  jncture  of  edema  is  found  (Fig.  71).  The  muscle- 
bundles,  and  in  some  instances  the  muscle-hbers,  are  separated  from  one  another 
bv  serum,  recognized  in  the  section  as  Hocculent  or  ti'raiiulai'  matei'ial  which  takes 


hyalixp:  and  cystic  degexeratiox. 


89 


the  cosin  stain  faintly.  Lying  in  this  serum  are  isolated  muscle-fibers  cut  either 
transversely  or  longitudinally.  These  are  much  swollen  and  on  cross-section 
remind  one  of  the  swollen  exfoliated  epithelium  often  found  in  a  hydrosalpinx. 
Evidently,  as  a  result  of  maceration,  some  of  the  muscle-fibers  have  lost  their 
nuclei. 

Liquefaction  of  the  Hyaline  Tissue  with  Cyst  Formation. — On  section,  the 
myoma  contains  one  or  more  translucent  areas,  which  remind  one  of  an  apple 
containing  a  ''water  co¥e."  Such  areas  are  well  seen  in  Fig.  74  (p.  95).  As 
the  degeneration  advances  portions  of  these  translucent  areas  become  trans- 
parent and   are  seen  to  be  filled  with 

clear,      serous-like     fluid.      Traversing  " 

them  are  delicate  trabecukr.  AMth  the 
continued  degeneration  the  areas  con- 
taining clear  fluid  increase  and  one  area 
may  merge  gradually  into  another. 
Thus  in  one  myoma  we  may  have  the 
ordinary  myomatous  tissue,  translucent 
areas,  transparent  areas,  filled  with 
clear  fluid,  and  the  definite  cystic 
spaces. 

This  form  of  degeneration  occurs 
rarely  in  submucous  myomata,  more 
commonly  in  interstitial  nodules,  and 
most  freciuently  in  subperitoneal  tu- 
mors. It  may  be  limited  to  a  small 
area,  as  in  Fig.  75  (p.  96),  or  involve 
nearly  half  the  tumor,  as  in  Fig.  76 
(p.  98) ;  or  it  may  be  scattered  through- 
out the  entire  tumor  (Fig.  116,  p.  160). 
In  Fig.  79  (p.  101)  large  and  small 
cystic  spaces  are  scattered  every whcn-e 
throughout  the  tumor  and  divided  into 
smaller  spaces  by  trabecuke.  Occa- 
sionally the  tumor  may  undergo  almost 

complete  cystic  transformation,  as  seen  in  Fig.  M  (p.  lOL'i.  in  wliidi  :i  portion 
of  the  tumor  was  like  a  ball  of  jelly  having  delicate  trabecuhe  rumiing  thiMugii 
and  dividing  it  into  large  and  small  C()mj)artmeiits. 

The  cyst  fluid  is  usually  straw-colored,  lim|)i(k  and  tiickles  away  fi'oin  the 
cut  surface.  In  most  cases  it  coagulates  on  exposuic  to  the  air.  but  occasion- 
ally remains  liciuid. 

Histologic  A  p  |)  e  a  1'  a  n  c  e  s  of  .M  y  o  in  a  t  a  l'  n  d  e  r  g  o  i  n  g 
L  i  ([  u  e  f  a  c  t  i  o  n  . — In  I'ig.  fi7  (j).  SI)  we  liaA'e  a  good  example  of  diffuse  and 
sharj)ly  defined  hyaline  degeiieiat  ion.     .\fter  a  t  inie  t  his  hyaline  t  issue  undergoes 


Fig.    72. — Hyalixe    Dkgeneratio.v     with    Cystic 
Formation  in  a  Small  Scbperitoneal    Ped- 
unculated Myoma.     (Nat.   size.) 
Gyn.   No.  4415.     Path.   No.   1207.     The    upper 
l)art   of  the  myoma  has  undergone   tyi)ical    hyaline 
degeneration,  as  seen  at  a;  at  b  tliis  has   gone  on  to 
cyst   formation.     Ct)vering  the  outer  surface  of    the 
cyst    is   a   well-marked    zone   of    myomatous   tissue. 
It  will  l)e  noted  that  the    degeneration  is  at  a  point 
most  remote  from  the  source  of  lilnod-supply. 


90  MVO.MATA    OF    THE    ITKHIS. 

softening.  The  softening  rcniinds  one  very  much  of  the  uneven  melting  of  a  largo 
sea  of  ice  on  a  hot  sj)ring  day.  In  some  places  it  is  still  dense,  in  others  fairly 
thick  yet  rarefied:  and  where  the  heat  has  been  most  intense,  the  ice  has  almost 
disapjM'ared.  Tn  the  hyaline  areas  the  tissue  at  first  takes  the  eosin  stain  uni- 
formly. A  little  later  there  ai'e  certain  areas  whei-e  the  eosin  stain  has  faded, 
owing  to  the  thinning  out  of  the  hyaline.  Still  later  the  hyaline  has  entirely  dis- 
aiJpeared  in  the  rarefied  areas,  leaving  them  threadbare,  so  to  speak,  and  showing 
tile  hbrillary  arrangement  of  the  remaining  fibrous  tissue:  and  finally  there  re- 
main s])aces  filled  with  a  fine  granular  deposit — coagulated  serum. 

Some  of  these  spaces  are  traversed  by  minute  trabecuhe  consisting  of  minute 
capillaries,  just  sufficiently  wide  to  allow  one  red  blood-corpuscle  to  pass  at  a 
time. 

In  Fig.  82  (p.  103)  can  be  seen  extensive  hyaline  degeneration,  although 
in  })laces  the  muscle-bundles  and  individual  muscle-fibers  are  still  preserved. 
Nearly  all  the  hyaline  material  has  vanished,  only  the  fibrillatcd  connective 
tissue  remaining,  and  at  /  even  this  has  disap|)eai'ed,  nothing  luit  li(iuid  being 
left.  Fig.  83  (p.  104)  is  even  more  instructive.  A  few  nmscle-fibers  and  bundles 
still  persist;  the  majority  of  the  muscle-bundles  have  been  converted  into 
hyaline  tissue.  They  stain  with  eosin,  stand  out  sharply,  and  are  easily  differen- 
tiated from  the  stroma,  which  has  also  undergone  hyaline  degeneration.  In  the 
center  of  the  field  the  tissue  has  completely  melted  away  and  we  have  an 
irregular  cavity  filled  with  coagulated  serum,  recognized  as  granular  material. 

Probably  the  most  instructive  picture  in  the  series  is  Fig.  84  (p.  106).  It  is 
from  a  degenerated  myoma  noted  during  pregnancy.  In  the  upper  part  of  the 
field  are  a  few  bundles  of  swollen  muscle-fibers.  The  great(>r  part  of  the  picture 
consists  of  hyaline  material  that  has  undergone  licjuefaction.  The  darker  areas 
indicate  the  amount  of  albumin  held  in  the  solution  and  all  gradations  in 
density  can  be  traced  until  we  have  areas  in  which  the  fluid  contains  practically 
no  albumin  and  the  spaces  are  almost  colorless.  This  process*  of  liquefaction 
gradually  advances  until  we  have  ninnerous  small  cysts,  limited  to  one  j)ortion 
01-,  as  is  frequently  the  case,  scattered  throughout  various  portions  of  the  tumor. 

Hyaline  Degeneration  with  the  Formation  of  Large  Cysts  in  the  Myomata. — 
L'rom  the  |)i'eceding  pages  we  have  seen  that  the  hyaline  areas  in  the  myomata 
gradually  undei'go  li(|Uefaction  and  that  ^uiixW  cy.st-like  spaces  are  developed. 
It  has  further  been  noted  that  these  are  not  true  cyst  sjxices,  as  they  are  merely 
the  reservoirs  of  the  broken-down  tissue  and  their  walls  are  conqiosed  of  ragged 
hyaline  tissue.  Naturally,  such  cavity  formations  have  neither  an  epithelial 
nor  an  endothelial  lining. 

With  the  gradual  disintegration  of  the  tumor  it  is  only  natural  that  \hr  cystic 

*  In  tlie  following  cases  small  cyst-like  spaces  were  noted  in  the  degenerated  myomata: 
Nos.  2718,  3107.  3113,  3488.  .3498,  3622,  36G1,  .3882.  3977,  3991,  4172.  441.5,  4635,  4894.  .5021, 
5058,  5141.  5325,  6272.  7511.  9924,  10573,  11806.  12194.  12779.  12864,  C.  H.  I.  Petli.,  San. 
1011,  San.  1924,  C.  H.  I.  \V.,  C.  H.  I.  1019 


HYALIXE    AXD    CYSTIC    DEGF.XKUATIOX.  91 

spaces  should  increase  in  size,  first  by  the  gradual  crunibUng  down  of  their  own 
walls  and,  secondly,  by  the  merging  into  them  of  other  cystic  spaces,  the 
process  in  so  far  being  analogous  to  that  which  occurs  in  a  multilocular  ()\;irian 
cyst. 

In  Fig.  85  {]).  107)  we  have  an  excellent  example  of  an  interstitial  inyoina 
that  has  been  converted  into  one  hirge  cavity  and  has  trabecuhe  extending  from 
side  to  side.  Its  walls  were  composed  of  friable  hyaline  tissue.  It  was  filled 
with  a  clear  serous  fluid. 

The  myoma  in  Fig.  86  (p.  109)  measured  23  x  25  x  81  cm.  It  had  been  con- 
vert (hI  into  one  large  cavity,  the  walls  being  composed  of  shaggy  tissue,  and  con- 
tained a  central  core  of  shaggy  tissue  held  in  place  by  trabecuhp  extcMiding  to  the 
cyst-walls.  The  core  and  the  trabecular  represented  the  more  resistant  portions  of 
the  tumor  which  had  not  gone  on  to  liquefaction.  The  cavity  was  filled  with  a 
turbid,  greenish-brown  fluid. 

In  Fig.  87  (p.  110)  the  process  has  gone  on  more  slowly,  there  being  large  and 
small  cyst  spaces  and  much  tissue  that  has  undergone  only  partial  disorganization. 

In  Fig.  89  (p.  113)  we  have  a  large  subperitoneal  myoma  that  presents  a  hone}-- 
combed  appearance  and  also  contains  several  large  cystic  cavities.  \\\'iv  the 
uterus  hidden  and  the  outer  muscular  covering  obscured,  the  tumor  might 
readily  be  mistaken  for  a  nmltilocular  ovarian  cyst. 

The  cystic  tumor  seen  in  Fig.  90  (p.  114)  is  evidently  an  old  one.  The  hyaline 
tissue  to  a  great  extent  has  become  licjuefied,  and  there  have  be(>n  numerous 
secondary  cavities,  as  indicated  by  the  trabecuhe  which  carry  blood-vessels  (Fig. 
91,  p.  115). 

The  multilocular  cystic  tumor  noted  in  Fig.  92  (p.  117)  is  a  most  unusual  one 
and,  looking  at  it  casually,  one  could  very  readily  mistake  it  for  an  ovarian  cx-st. 

These  tumors*  may  reach  very  large  proportions.  In  No.  13025  the  myo- 
matous uterus  weighed  39  pounds,  the  greater  part  of  the  tumor  being  made  ui> 
of  one  cyst  (Fig.  93,  p.  119).  With  the  abdomen  open  we  at  hrst  felt  sure  that 
we  were  dealing  with  an  ovarian  cyst,  and  it  was  only  when  wo  reached  the  jH'dicle 
that  the  true  nature  of  the  mass  was  determined,  (^ur  largest  cystic  myoma 
weighed  89  pounds.     It  is  described  in  detail  on  ]).  512. 

Fluid. — The  cyst  fluid  is  usually  straw-colored.  In  the  small(>r  cysts  it 
usually  coagulates  on  exj)osur(>  to  the  air,  but  in  the  largei'  ones  olten  ivinains 
li(|uid.  In  No.  7049  the  fluid  was  turbid  and  givenish  brown  in  color.  Willi 
the  disintegration  of  the  tumor  theic  may  be  hemorrhage  into  the  cavitw  .and 
then  the  fluid  is  red,  reddish  brown,  oi'  cliocol;ii<'-coloivd,  .accoiding  to  the  length 
of  time  that  has  elapsed  since  the  bleeding.  In  .No.  122:11  I  he  ca\ily  was  lilled 
with  |)ale  clots. 

The  cystic  myoma  repivseiited  in  JMg.  90  (p.  122)  is  a  most  unusual  one  and 

*  In  the  t'ollowing  cti.scs  liyaliiie  dogent'nitioii  aiui  larsic  cystic  spaces  were  noted:  Nos.  0,39, 
1628,  1672,  I!)(H»,  :^  t  tO,  :?44.").  3.-)2.3,  3960,  1  IS.").  t,S2S,  M:i2.  70 19,  .SSS2,  91  IS,  104GI,  12234,  12488, 
1.3423,  1362.-),  San.  192.-),  ('.  II.  I.  1'.,  C  11.  I.  1296. 


92  MYOMATA    OF    THE    ITKRUS. 

Ix'ars  a  striking  rcsciiihlancc  to  the  interior  of  a  heart.  It  was  lined  with 
myomatous  muscle,  had  no  endothelial  lininiz:,  and  was  fille(l  with  a  clear  Huid. 

On  histologic  examination  we  have  found  that  nearly  all  these  cystic  si)ace.s 
are  linetl  with  hyaline  material.  This  occasionally  bears  evidence  of  an  old 
hemorrhage,  as  is  indicated  by  the  yellow  pigment  in  San.  No.  1925  and  by  the 
deposit  of  brown  granular  pigment  in  Xo.  3960. 

C  a  u  s  e  of  Cystic  Degeneration  of  M  y  o  m  a  t  a  . — In  the  vast 
majority  of  the  cases  the  hyaline  degeneration  is  the  primary  factor.  Dilatation 
of  the  lymi)hatics.  however,  may  occasionally  be  partly  responsible  for  some  of 
the  cystic  spaces,  as  indicated  by  the  two  following  cases: 

In  Xo.  3113  a  tumor,  25  cm.  in  diameter,  had  sprung  from  the  posterior  wall 
of  the  uterus.  On  section,  it  was  whitish  in  color,  and  presented  a  finely  striated 
ai)i>eai-ance.  Scattered  everywhere  throughout  the  tumor  were  sinuses,  the 
largest  being  1.2  cm.  in  diameter.  These  sinuses  had  smooth  walls  and  communi- 
cated with  numerous  smaller  ones.  On  histologic  examination  the  tumor  was 
found  to  be  edematous  in  i)laces.  Some  of  the  large  and  small  spaces  had  an 
endothelial  lining.  In  others  no  lining  could  be  found.  As  the  blood  in  the 
arteries  and  veins  had  been  well  preserved  in  Miiller's  fluid,  and  since  these 
spaces  were  comparatively  free  from  blood,  we  were  inclined  to  believe  that  they 
were  lymph-channels. 

In  Xo.  4S2S  a  cystic  myoma,  27  cm.  in  diameter,  had  s|)rung  from  the  uterus. 
There  was  one  large  cyst  and  numerous  smaller  on(>s.  On  histologic  examination 
the  cystic  spaces  were  found  to  be  due  in  ])art  to  li(iuefaetion,  luit  others  were 
evidently  dilated  lymph-s])aces.  as  proved  by  the  lining,  which  consisted  of  one 
layer  of  endothelium. 

Hyaline  Degeneration  of  Myomata  with  Emulsified  Fat  in  the  Cystic  Areas. — 
Almost  constantly  we  find  that  li(iuefaction  of  hyaline  material  yields  spaces  filled 
with  a  clear  yellowish  Huid,  but  in  two  instances  the  resultant  cavities  have  con- 
taincl-d  a  material  resembling  melted  butter.  In  Xo.  2852  the  posterior  wall  was 
occupied  by  a  myoma,  12  cm.  in  diameter.  This  contained  two  caviti(>s,  one 
measuring  2  x  2.5  cm.,  the  second  4.5  x  5  x  6  cm.  (Fig.  98,  p.  124).  Both  of  these 
spaces  had  convoluted  and  smooth  walls  and  were  lined  with  a  smooth,  butter- 
like material,  which  was  semisolid:  both  cavities  were  filled  with  a  liquid  which 
closely  resembled  melted  butter.  Histologic  examination  showed  that  the  my- 
oma had  undergone  moderate  hyaline  degeneration  and  that  the  walls  of  the 
cavities  were  composed  of  hyaline  material. 

Innnediate  examination  of  the  fluid  from  the  cavities  showed  that  it  con- 
tained many  cholesterin  crystals,  large  round  cells  filled  with  fat-globules,  and 
many  muscle-fibers  containing  fat-droplets.  There  was  much  granular  detritus. 
In  this  case  there  had  been  first  a  hyaline  degeneration  and  then  emulsification, 
or,  in  other  words,  fatty  degeneration  with  li(|uefaction  of  the  hyaline  material. 

In  X'(j.  3475  a  nodule,  4.5  cm.  in  diameter,  springing  from  the  right  side  of  the 
uterus,  contained  a  soft,  friable  central  portion  of  the  consistence  of  casein.     On 


HYALINE    AND    CYSTIC    DEGEXKHATIOX. 


93 


histologic  examination  nearly  the  entire  tumor  was  found  to  be  necrotic.  The 
creamy  material  from  the  center  of  the  myoma  was  composed  of  elongate  cells 
partly  filled  with  fat-droplets.  There  was  much  free  fat  and  here  and  there 
masses  of  cholesterin  crystals.  The  changes  in  this  case  were  analogous  to  those 
noted  in  the  preceding  one. 

Relation  of  Hyaline  Degeneration  to  Sarcoma. — Hyaline  degeneration  cer- 
tainly seems  to  favor  the  development  of  sarcoma.  The  cells  that  resist  the 
hyaline  change  lie  free  in  the  hyaline  tissue  or  in  the  serous  fluid  and  occasionally 
take  on  active  development.  This  subject  is  discussed  in  detail  in  the  cha})ter 
on  Sarcomatous  Transformation  of  Myomata  (p.  175). 


Detailed  Report  of  Cases  Showing  the  Various  Types  of  Hyaline  Degeneration. 

In  our  brief  description  it  has  been  impossible  to  describe  in  detail  the  various 
degenerative  changes.     ^\c,  therefore,  give  in  extenso  the  more  characteristic 
cases    which    portray   accur- 
ately   the    various    steps    in 
the  hyaline  degeneration. 

Gyn.  No.  751 1.  Path.  No. 
3757. 

Extensive  and 
sharply  d  e  fi  n  e  d 

hyaline  d  e  g  e  n  e  r  a  - 
t  i  0  n  in  a  s  u  b  p  e  r  i  t  0  - 
n  e  a 1  pedunculated 
Myoma    (Fig.  73). 

A.  D.,  aged  thirty,  mar- 
ried, black.  Admitted  Janu- 
ary 16;  discharged  February 
9,  1900. 

Path.  No.  3757.  The 
specimen  consists  of  a  myo- 
matous  uterus   with    its   a))- 

pendao'eS.       Th(^    bodv    of    the       Fk;.  7.3. — ExxENgivE  and  Sharply  Dkhnki)  Hyai  ink  DniiKN-KWA- 

TION   IN    A   SUBPKRITONKAI-  MyOMA.        (J    Iiat.  .size.) 

uterus      measures      0      cm.      m  ^^^    No.  7511.     Path.  No.    37r)7.     The    tumor    n'presi'iil.s    a 

lenffth       4  5     cm       in     br('a(hll  cross-section  of  a  subperitoneal  i)e<lunc'iiliit«'d  in.VDma,  7  xStx  10  cm. 

The  fourth    of    the    tumor    nearest    the    ix-ilicle   presents  thej usual 
and    3.5    cm.    in    its    ailtcropOS-         myomatoiis   appearance,   as   seen    at    .;.      I'ull.v  ihree-f.uirllis    of  tlie 

terior  diameter.  .Vntcriorly 
it  is  smooth  and  glistening. 
Posterioi'ly  it  is  covei'ed 
with  numerous  adhesions. 
Studding  the  uterine   walls  and   also   pi-ojecling    iVoni    the   surface   are   several 


tumor  is  mucli  hjihter  in  color  and  stands  out  in  sharp  eontnust 
with  the  unaltered  myomatous  tissue.  'I'he  line  of  demarcation 
is  well  shown  at  h.  In  the  larRe  hyaline  area  the  tihrousJarraiiKe- 
iiKiit  is  still  visilile.  The  center  of  the  deRenerated  area  has  broken 
down  and  contains  f;ranular  material,  as  seen  at  r. 


94  MVOMATA    OF   THK    UTERUS. 

small  iiiyoiiiata :  posteriorly,  near  the  cervix,  is  a  suhpcritoiical  nodule,  4.5 
cm.  in  diameter,  envelo|)ed  in  adhesions.  Tt  shows  an  area  of  hyaline  de- 
generation, 2.5  em.  in  diameter.  The  chief  interest  lies  in  a  subperitoneal 
myoma  springinii'  fi-om  the  left  side  (Fiji'.  ~-^)-  Tiiis  is  co^•ered  with  a  few 
omenta!  adhesions,  and  ])oslcriorly  is  pushiiiii  aside  the  folds  of  the  hroad  liga- 
ment. It  measures  7  x!)  x  10  cm.  On  .section  it  j)resents  a  very  unu.sual  pic- 
ture. One-fourth  of  its  .substance  consists  of  tyjVical  myomatous  tissue.  The 
remaining  three-fourths  is  light  in  color  and  very  shai'])ly  defined.  In  this 
light-colored  aica  the  central  i)ortion  has  melted  away  and  left  aji  irregular, 
ragged  cavity. 

Micro.scopically,  the  uterine  nuicosa  is  normal.  The  light  area  in  the  sub- 
peritoiu'al  myoma  consists  in  ])art  of  necrotic  tissue  entirely  devoid  of  nuclei, 
but  containing  large  and  small  calcareous  deposits.  Other  portions  show  some 
hyaline  degeneration.     The  appendages,  apart  from  adhesions,  are  normal. 

San.  1924.     Path.  No.  8824. 

M  a  r  k  e  d  h  y  a  line  d  e  g  e  n  e  rati  o  n  with  1  i  q  11  e  f  a  c  t  i  o  n 
of     an     interstitial     myoma     (Fig.   74). 

P..  aged  fifty-two,  married.     Achnitted  May  S;  discharged  June  13,  1905. 

Path.  No.  SS24.  The  tumor  is  irregularly  heart-shaped.  It  is  12  cm.  in 
length.  IS  cm.  in  breadth,  and  20  cm.  in  its  anteroposterior  diameter.  Tt  is 
smooth  and  glistening.  Attached  to  the  side  are  the  tubes  and  ovai'ies.  The 
great  inci-ctise  in  size  of  the  uterus  is  due  to  an  interstitial  notlule,  11  x  15  cm. 
It  is  sharply  circumscribed.  In  some  ])laces  the  myoma  is  perfectly  ))reserved, 
but  at  least  two-thirds  of  it  has  undergone  degeneration  (Fig.  74).  The  spaces 
are  filled  with  coagulated  fluid.  At  a  point  most  remote  from  the  uterus  there 
has  been  a  slight  breaking  down  and  the  cystic  si)aces -thus  formed  vary  from 
0.5  to  4  cm.  in  diameter.  The.se  have  .smooth  walls.  The  myoma  presents  the 
typical    ])icture    of    hyaline    degeneration,    with   .subsecjiu^nt    cystic    formation. 

Micr()sc()])icall_\'  the  myoma  shows  marked  hyaline  degeneration.  Scattered 
throughout  this  hyaline  material  are  little  bundles  of  muscle-fibers. 

Gyn.  No.  9924.     Path.  No.  61 18. 

Cystic  (1  e  g  e  n  e  |-  a  t  i  o  n  o  f  a  p  o  r  t  i  o  n  of  a  ])  e  d  u  n  c  u  - 
1  a  t  e  d    s  u  b  ]}  e  r  i  t  o  n  e  a  1    m  y  o  m  a     (Fig.  75). 

E.  S.,  aged  forty-nine,  married,  white.  Admitted  September  23:  di.<charged 
October  18,  1902. 

Path.  No.  (ills.  The  specimen  con.sists  of  an  irregular,  nmltinodular,  myo- 
matous uterus,  which  is  apjii'oximately  15  cm.  in  breadth  and  S  cm.  in  its  antero- 
posterioi-  diametei-.      .Vtt.ached  to  it  are  the  tubes  and  ovai'ies. 

The  utci'us  contained  pedunculated,  sessile,  interstitial,  and  subnuicous 
nodules.  ( )ne  pedunculateil  nodule  s])ringing  from  the  posterior  sui'face  is  aj)- 
))i'o\imately  (i  cm.  in  diameter  and  nmlberry-shaped,  there  being  litth'  nodules 


HYALIXE    AND    CYSTIC    DEGEXERATIOX. 


95 


projecting  from  its  surface  everywhere.     Attached  to  the  posterior  surface  of  the 
fundus  by  a  pedicle,  2  cm.  in  diameter,  is  an  oval  subperitoneal  nodule.  8  x  12  x  14 


(.  ■'- 


Fig.  74. — .Mahkkd  Hyaline  DF;c;E.NKHAri(>N  w  nil  Ln^i  ki-aci  io.n  oi-  an  In  tkhsti  ii  ki.  M  vo.m  v.     (■  nut.  size.) 
San.  No.  1924.     Path.  No.  8824.     The  incUiie  lepieseiits  an  ol)li(iii(>  sectimi  llimuuli  llu-  uterus;  tlio  ulctine 
cavity  has  not  been  entered. 

The  interstitial  myoma  is  11  x  15  em.  a  indicates  the  outer  eoveriiiK  <>f  uterine  niuschs  l>  the  juiu-linn 
of  the  myoma  with  the  muscle.  The  greater  jiart  of  the  myoma  has  underRnne  iiyaline  defeneration  with  liiiue- 
faction,  the  litiuefied  areas  reminding  one  of  the  "water  eore"  occasionally  seen  in  an  ai>i)le.  The  liiiuefieil  areas 
are  well  seen  at  d.  Scattered  throughout  the  deKeiierated  areas  are  irrcKular  patches  of  typic.-d  myomatous  (issue, 
the  largest  area  being  at  r.     In  some  jjlaces  the  licpiefied  areas  have  gone  on  to  cyst  formation,  as  designatctl  at  t. 


cm.  (Fig.  75).  It  is  partly  solid,  pjirlly  cystic.  <  )ii  section,  the  portion  nearest 
the  uterus  seems  to  be  firm,  but  about  one-sixth  of  the  luiiioi-,  at  a  jioiiit  remote 
from  the  pedicle,  is  soft  and  cystic  and  much  jialei-  in  color.     This  cystic  ])ortion 


96 


MYOMATA    OF    TIIK    UTKUrS. 


is  filled  with  clear  Huid  aiul  tliffer.s  markedly  in  eoloi'  fr(»iii  the  ordinary  inyomat- 

ous  tissue.  The  line  of  de- 
marcation is  exceedingly 
sharp,  the  tumor  pri'sent- 
in<2;  a  ratlier  porous  ap- 
pearance and  being  yel- 
lowish white  in  color. 
Where  the  degenerative 
process  is  markedly  ad- 
vanced, the  tissue  is  honey- 
combed and  we  then  have 
irregular  spaces,  with  deli- 
cate    trabecuhe     running 


Fig.  75. — Cystic  Degeneration  of  a  Portion  of  a  Pedunculated,  Subperitoneal  Myoma.     (?  nat.  size.) 

Gyn.  No.  9924.  Path.  No.  6118.  The  uterus  contains  numerous  nodules.  Springing  from  the  right  and 
anterior  a.spect  of  the  fundus  is  a  subperitoneal  pedunculated  myoma,  8  x  12  x  14  cm.  The  upper  portion  (a)  has 
undergone  hyaline  degeneration,  with  subse<iuent  liciucfaction.  Traversing  the  cavity  everywhere  are  large  and 
small  trabecula>,  dividing  the  degenerated  area  into  cystic  spaces  of  different  sizes.  These  were  filled  with  a  clear, 
straw-colored  fluid. 

Histologic  Examination. — The  walls  of  the  cystic  spaces  are  composed  entirely  of  hyaline  tissue,  and  there  is 
no  endothelial  lining. 

It  is  interesting  to  note  that  the  degeneration  has  occurred  at  the  point  farthest  removed  from  the  source  of 
blood-supply — the  pedicle.  Projecting  from  the  surface  of  the  uterus,  between  the  Fallopian  tubes,  is  a  small 
nodule.  The  upper  half  is  very  pale,  as  indicated  by  b.  The  pallor  is  due  to  hyaline  degeneration  occurring  in 
this  myoma  also. 

The  Fallopian  tubes  are  somewhat  thickeiied.  Bnth  fimbriated  extremities  are  free.  The  tubes  were  the  seat 
of  tuberculosis.     The  endometrium  also  showe  1  an  early  tuberculous  process. 


acro.ss  them, 
liquefaction. 


The    picture   is   typical    of    hyaline    degeneration    with    gradual 


HYALIXE    AND    CYSTIC    DEGEXERATIOX.  97 

Microscopically  the  area  of  degeneration  consists  entirely  of  hyaline  tissue. 
This  tissue  is  devoid  of  nuclei  except  for  a  little  rim  on  the  outer  surface.  Here 
the  muscle-fibers  are  still  preserved.  The  trabecuUe  traversing  the  cavities  con- 
sist of  hyaline  tissue  that  stains  a  little  deeper  than  that  filling  some  of  the  spaces. 
It  contains  some  calcareous  ])lates.  Examination  of  the  uterine  mucosa  shows 
tuberculosis  of  the  endometrium.  There  was  also  tuberculosis  of  both  tubes,  and 
the  adhesions  around  the  uterus  contained  tubercular  nodules. 

Gyn.  No.   12864.     Path.  No.  10311. 

A  large  m  u  1  t  i  n  o  d  u 1  a  r  m  y  o  m  a  t  0  u  s  u  t  e  r  u  s  with  a 
huge  s  u  b  p  e  r  i  t  o  n  e  a  1  {)  e  d  u  n  c  u  1  a  t  e  d  m  y  o  m  a  u  n  d  e  r  - 
going  cystic   degeneration    (Figs.  76  and  77). 

M.  B.,  married,  aged  forty-four,  black.  Admitted  April  21:  discharged 
May  23,  1906.  In  this  case  the  enlargement  of  the  abdomen  was  first  noticed 
fifteen  years  ago.  The  growth  has  been  slow.  Seven  years  later  her  physician 
diagnosed  a  myoma,  but  advised  against  operation.  The  abdominal  enlai'ge- 
ment  steadily  increased.  For  the  last  five  months  there  has  been  some  jiain  in 
the  lower  part  of  the  back  and  in  the  abdomen  after  exertion.  For  three  months 
there  has  been  rapid  growth  of  the  tumor.  The  patient  has  not  been  incapaci- 
tated or  inconvenienced  seriously  until  within  the  last  three  or  four  months. 
During  the  last  few  days  there  has  been  considerable  difficulty  in  mictui'ition. 

At  operation  the  omentum  was  found  to  be  markedly  adherent.  Tlu^  omen- 
tal vessels  were  greatly  dilated.  The  tumor  was  very  soft  and  strongly  sugges- 
tive of  sarcoma.  It  bled  with  the  utmost  readiness.  It  was  so  densely  adherent 
that  during  its  removal  the  left  side  of  the  bladder  was  opened.  The  patient 
made  a  very  satisfactory  recovery. 

Path.  No.  10311.  The  specimen  consists  of  a  huge  multinodular  myomat- 
ous uterus,  20x25x28  cm.  The  myomata  have  undergone  hyaline  degenera- 
tion. Attached  to  the  left  side  of  the  uterus  is  a  large  ])edunculated  myoma 
(Fig.  76).  Its  upper  half  presents  the  usual  myomatous  a])])earance.  The 
lower  half  has  undergone  marked  degeneration,  is  dark  in  color,  and  contains 
numerous  cystic  spaces. 

Histologic  Examination. — In  the  degenerated  ])ortion  of  the  myoma  there  is 
coagulation  necrosis  and  also  a  good  deal  of  hyaline  degeneration.  The  cystic 
spaces  are  devoid  of  nuclei,  showing  neithei-  eiidoihelial  nni-  ejiiihelial  lining. 
In  certain  parts  of  the  myoma  the  en.lotheliiiin  of  the  c.aiiillaries  has  piolilei-ated 
to  such  an  extent  that  the  muscle-fiheis  are  di\ided  up  into  ahcoli  i  l-'ig.  77t. 
At  hrst  sight  one  might  \'eiy  I'eadily  diagnose  a  malignant  growth.  .\t  other 
points  there  is  a  typical  hyaline  degeiieiation. 

Gyn.  No.  3991.     Path.  No.  990. 

Disintegration  o  f  t  h  e  c  e  n  t  i'  a  1  p  o  v  I  i  o  n  o  f  a  n  i  n  t  e  r  - 
s  t  i  t  i  a  1    m  y  o  ma    ( Fig.  78). 


Fig.  76, 
98 


HYALIXE    AND    CYSTIC    DEGEXEUATIOX. 


99 


L.  N.,  single,  aged  forty-seven,  white.  Admitted  November  29;  discharged 
December  30,  1895. 

Path.  No.  990.  The  specimen  consists  of  the  uterus  with  the  appendages. 
The  uterus  is  globular  in  shape  and  approximately  10  em.  in  its  various  diam- 
eters. Scattered  over  its  surface  are  several  small  subi)eritoneal  nodules,  vary- 
ing from  1  to  3  cm.  in  diameter.     The  uterus  is  covered  with  numerous  adhesions, 


Fig.  77. — Marked  Proliferation  of  thf.  Endothelium  of  the  Capillaries  Dividinc;  the  Mvomatois  Tissue 

INTO  Alveoli.     (X120diani.) 
Gyn.  No.  12864.     Path.  No.  10.311.     The  myomatous  tissue  presents  the  usu.al  appearance,  but  ilividiug  it 
up  into  fairly  regular  alveoli  are  deeply  staining  bands  of  tissue.     These  dark-staining  cells  are  proliferated  and 
deeply  staining  endothelial  cells  of  the  blood-capillaries.     The  picture  is  a  most  unusual  one. 

those  on  the  posterior  surface  being  rather  dense.  On  pal])ati()ii  it  is  rather  solt 
and  yielding,  giving  an  indistinct  sensation  of  fluctuation.  The  uterine  cavity 
is  9  cm.  in  length,  at  the  fundus  5.5  cm.  in  bn^adtii:  the  mucosa  is  rouglient'd  and 
corrugated  in  appearance.  The  portion  covering  the  jxjsterior  surlace  near  the 
right  cornu  ])resents  an  area  of  thickening  1  cm.  in  diameter,  and  (■(•Mtains  nu- 
merous dilated  glands,  varying  in  size  from  a  pin-|)oinl  to  1  mm.  Situated  in  the 
anterior  uterine  wall  are  several  firm  white  lu.dules.  varying  from  0.5  to  3  cm.  and 


Fig.  76. — Cystic  Degeneration  in  a  Laucje  Si'ih-ekitonkal  I'i.di  n<  i  i.aii-.i>  .M^omx.  .,.  "•"■  -i'<  ■ 
Gyn.  No.  12864.  Path.  No.  10311.  To  the  right  is  an  enlarged  inyoinaloua  uterus,  reoogniwible  by  the  left 
tube  and  ovary  above  and  the  rro.ss-section  of  the  cervix  below,  n  is  the  small  pedicle  ronnecting  the  large  tumor 
with  the  uterus.  Attached  to  the  lower  end  of  the  tumor  i.s  a  broad  omental  adhesion.  Hejow  the  line,  between 
b  and  //,  the  peritoneal  covering  is  of  a  darker  hue  and  tlie  surface  is  smooth,  suggesting  .legcnerative  changes  in 
this  portion  of  the  tumor.  The  ui)i)er  part  of  the  myoma,  on  section,  presents  the  usual  appearance.  Near  the 
middle  are  small,  .smooth-walled  cysts.  The  lower  lialf  of  the  tumor  is  much  darker  in  color,  owing  to  the  de- 
generative change,  and  contains  numerous  cystic  spaces.  lliNlol.igii-  c\Mniiii:ilioii  -.|„,w>  ihni  (he  chief  changes  are 
due  to  hyaline  degeneration  of  the  tumor. 


100 


MYO.MATA    OF    TIIK    LTKHIS. 


presenting  the  typical  myomatous  appearance.  The  posterior  wall  is  occupied 
by  a  tumor  8  cm.  in  diameter  (Fig;.  78).  This  tumor  is  surrounded  by  a  di.-<tinct 
capsule  of  uterine  muscle,  varying;  from  0.6  to  2.5  cm.  in  thickness.  On  section, 
it  is  found  to  be  composetl  of  bunches  of  fil)ers  concentrically  and  irregularly 
arrang;ed.  Its  entire  central  portion  over  an  area  5  cm.  in  diameter  has  degen- 
erated and  contains  a  tenacious,  semisolid  material. 


cav 


Fol 


ji.SecHeii 


Fic.  78. — Co.'^GOL.vTioN  Necrosis  and  Hyaline  Degexer.\tiox  ok  ax  Interstitial  Myoma.     (  ",  iiat.    size.) 
Gyn.  No.  .3991.     Path.  No.  990.     a  is  one  of  several  small  niyoinata  occupying  the  anterior  wall.     In  the 

uterine  cavity  near  the  cervix  is  a  small  polyp.     Occupying  the  posterior  wall  is  a  myoma  S  cm.  in  diameter.     The 

central  portion  ha.s  broken  down,  forming  an  irregular  cavity  x^d)  filled  with  a  tenacious,  semisoliil   material.     At  c 

is  a  colony  of  small  cysts. 

On  histologic  examination  the  degenerated  area  was  found  to  consist  partly  of  hyaline  material  and  partly  of 

tis.sue  that  had  undergone  coagulation  necrosis,  with  fragmentation  of  the  nuclei. 


Histologic  Examination. — The  nodules  in  the  uterine  walls  present  the  usual 
appearance,  and  the  degenerated  myoma  occupying  the  posterior  wall  is  likewise 
compo.sed  of  non-striated  mu.scle-fibers  undergoing  coagulation  necrosis.  The 
central  portion  is  represented  Ijy  a  pale-staining  fibrillated  or  almost  homoge- 
neous material  from  which  the  nuclei  have  disappeared,  but  in  other  ])ortions. 


HYAI.IXK    AND    CYSTIC    DEGKXKHATIOX, 


101 


lurgc  nunilx'r.s  of  l'ragim'iit('(l  nuclei  aiv  seen.     (_)n  i)assing  toward  the  uterine 
muscle  the  degeneration  becomes  less  marked. 

San.  No.  loii.     Path.  No.  4508. 
General    a  n  d    d  i  ft'  u  s  e    c  y  s  t  i  c    f  o  r  m  a  t  i  o  n    i  n    a     m  y  o  m  a 
(Fig.  79). 


,ty 


C  e  r  V  1 
Fig.  79. — General  and  Dikkusk  Cystic  Iohmation  in  a  Myoma,     {'i  nat.  size.) 

San.  No.  1011.  Path.  No.  4.508.  o  indicates  the  upper  limit  of  the  uterine  cavity.  The  Rreiil  incn-xM-  in 
size  of  the  uterus  is  due  to  an  interstitial  and  degenerated  myoma.  Inward  it  extends  to  the  mucosa;  outward  il 
is  covered  with  a  zone  of  normal  uterine  muscle.  The  line  of  junction  lict  ween  the  nuiscle  and  the  myoma  is  sliarpiy 
defined,  as  indicated  by  6.  The  tissue  jMcsents  a  diffuse,  honeycomlicd  appearance.  The  <-ysts  are  of  different 
forms  and  traversing  them  are  broad  and  also  delicate  trabecuhc.     'I'he  cyst-spaces  were  tilled  with  lliiiil. 

In  the  solid  portions  of  the  tumor  the  typical  myomatous  tissue  is  still  preserved,  but  shows  abumlant  Ijyalitie 
degeneration.  The  walls  of  the  cavities  coiisi-l  cliicdN  of  li.\  aline  material.  Tli.-  cavities  wereilevoid  of  any  epithe- 
lial or  eniiothelial  lining. 


J.  H.  T.,  aged  fift\'-thn'c,  white,  iiiaiTicd.  .\iliiiille(l  ()ct(ilier  I."):  discharged 
November  22,  1900.  In  this  case,  at'tei-  doing  a  liy.^tei-ectoiiiw  tiie  dperator 
removed  several  gall-stdiies. 

Path.  No.  -loOS.     The  speciineii  consists  of  a  large  niyonialous  uterus  with 


102  .MVOMATA    OF   THF-:    UTERUS. 

the  tul)rs  and  ovaries  attaclu'd.  The  tumor  incasurcs  approximately  IS  em.  in 
diameter.  It  is  everywhere  soft  and  elastie,  and  is  covered  with  perfeetly 
smooth  peritoneum.  On  section,  the  tumor  is  seen  to  consist  of  a  thin  wall,  1  cm. 
in  thickness,  with  an  interior  filled  with  a  brain-like  substance  (Fig.  79).  The 
growth  is  really  a  cyst,  with  remnants  of  the  muscular  tissue  occurring  as  a  cen- 
tral ma.ss,  supported  by  delicate  trabecuhe  extending  to  the  outer  wall.  The 
spaces  wen^  filled  with  a  iluid,a))))arently  serous  in  character,  l)ut  as  the  specimen 
was  hardened  before  being  opened,  no  definite  statement  can  be  made. 

Histologic  Examination. — Sections  through  the  capsule  of  the  tumor  show 
that  it  is  made  up  of  fibrillated  connective  tissue  and  non-striped  muscle-fibers. 
Sections  from  the  large  cystic  myoma  show  that  it  consists  of  myomatous  tissue, 
in  most  ])laces  the  seat  of  a  considerable  degree  of  hyaline  degeneration.  In 
other  j)laces,  however,  the  muscle-bundles  present  the  usual  appearance.  In 
some  portions  of  the  tumor  the  tissue  has  absolutely  lost  its  structure  and 
nothing  remains  except  large,  pale-staining  areas,  which  have  scattered  through- 
out them  groups  of  large,  swollen,  spindle-shaped  and  round  cells.  These  are 
undoubtedly  swollen  muscle-fibers  which  have  l)een  cut  longitudinally  and 
transversely.  At  first  sight  they  .suggest  sarcoma  cells,  but  there  is  no  evidence 
of  any  activity.     The  cyst-spaces  show  no  evidence  of  an}'  endothelial  lining. 

Gyn.  No.  3345.     Path.  No.  616. 

M a  r  k  e  d  c  y  s  t  i  c  d  e  g  e  n  e  ration  of  p  o  r  t  i  0  n  s  o  f  a  m  y  o - 
m  a  that  h  a  d  u  n  d  ergo  n  e  h  y  a  1  i  n  e  degeneration  (  Figs. 
SO  and  81) . 

E.  Z.,  married,  aged  forty-three,  colored.  Admitted  February  25;  discharged 
April  4,  1895.     Three  years  ago  the  patient  noticed  a  bearing-down  feeling  in 

the  abdomen  and  two  and  a  half  years  later  a  lump 
just  below  the  umbilicus.  This  was  approximatel)^ 
4  X  4.5  X  5.5  cm.  It  has  groAvn  rapidly  since  its 
ap})earance,  but  has  not  been  associated  with  any 
pain. 

Path.  No.  616.     The  s])ecimen  comprises  the  en- 
larged uterus,  with  a  tumor  springing  from  its  right 
side,  and  the  appendages.     The  uterus  is  oval  in  con- 
FiG.  80.— Gyn.    \o.   .3.34.5.     tour,  mcasuring  10  X  12  X  16  cm.     Springing  from  its 

Path.   No.  616.     The  general  con-  ,       .  i  ^       •  p  i     i  ^•^ 

tour  and  relations  of  the  myoma  antcHor  aud  postcnor  surtaccs  are  several  dome-like 
seen  in  Fig.  81.  iiodulcs,  the   largest   of    these    being  4  cm.  in  dia- 

meter. Projecting  from  the  right  side  of  the  uterus  is 
a  kidney-.'^haped  tumor,  12x13x21  cm.  (Figs.  80,  81).  This  is  smooth  and 
glistening,  and  in  many  places  traversed  by  numerous  blood-vessels.  It  is  at- 
tached to  the  side  of  the  uterus  by  a  short  pedicle,  4  cm.  in  diameter.  On  pal- 
pation the  tumor  is  soft  and  gives  one  the  impression  of  being  cystic.  It  has  an 
outer  and  firm  rim,  varving  from  0.5  to  1  cm.  in  thickness,  but  the  entire  cen- 


Fig.  81. — Complete  Cystic  Degener.'VTIon  of  Portions  of  a  Myoma  that  had  UNi)KR<iONE  Hyaline  Oegenkr- 

ATio.N.     (Nat.  size.  1 

Gyn.  No.  3345.  Path.  No.  616.  The  relation  of  the  tumor  to  the  uterus  is  iiulicuteii  in  Vig.  SO.  1  In-  st-ction 
here  depicted  was  obtained  by  cutting  into  one  end  of  the  peduncuhited  noilule. 

The  outer  covering  consists  of  uterine  muscle  which  is  much  congested.  (Occupying  the  entire  n-nter  ..f  the 
field  is  a  lemon-colored  cystic  mass.  Dividing  the  tumor  into  large  and  small  cysts  wore  delicate  trabecuhr,  many 
of  which  carried  delicate  blood-vessels.  On  cutting  into  the  mass  clear,  serous-like  (lui.i  escapiil  iiikI  soon  coagu- 
lated, forming  a  delicate,  jelly-like  ma.ss.     Other  portions  of  the  tumor  presente«i  the  characteristic  hyaline  changes. 

Unless  one  has  seen  such  tumors,  he  might  .loubt  the  accuracy  of  the  coloring,  but  Mr.  Brudel  was  fortunately 
on  hand  just  as  the  specimen  was  cut  and  caught  the  various  hues  perfectly. 


HYAl.IXE    AXI)    CVSTIC    DKCKX KUATK )\.  103 

tral  portion  is  soft  and  l)n'akinii;  down.  Traversing  sonic  ))ortion.s  of  the 
center  is  an  irregular  core  of  solid  tissue  which  is  attached  to  the  outer  wall  in 
various  places.  One  portion  of  the  section,  however,  is  entirely  cystic;  it  is  of  a 
lemon  color  and  is  traversed  by  delicate  trabecula\  On  cutting  into  it  sei'ous 
fluid  escaped,  which  soon  coagulated  (Fig.  81). 

Histologic  Ivxaniination. — The  large  and  degenei-ated  nodule  to  the  right  of 
the  uterus  is  coniposetl  of  non-striped  muscle-fibers.  Between  the  Inmdles  and 
muscle-fibers  are  numerous  homogeneous  areas  of  hyaline  degeneration  in  \\hich 
remnants  of  muscle-fil)ers  are  still  visible.  This  hyaline  change  becomes  more 
marked  as  one  passes  toward  the  center,  \\hei-e  the  tissue  appears  as  one  mass  of 
hyaline  material.  .Scattered  throughout  it  are  occasionally  small  bundles  of 
muscle-fibers.  The  hyaline  material  in  turn  gradually  dissolves  and  is  lost,  a 
delicate  reticulum  remaining.     This  was  the  jucture  obtained  in  the  cystic  areas. 

Gyn.  No.  12522.     Path.  No.  9233. 

Mark  e  d  h  y  aline  d  e  g  e  n  e  r  a  t  i  o  n  o  f  a  m  y  o  m  a  w  i  t  h 
g r a  dual     1  i  ( |  u  e  f  a  c  t  i  o  n     of     t  h e     h y  aline     t  i  s  s  u  c   (Fig.  82) . 


M 


iff'- 


^    ,:'      v^-,  /  ,    ..;.  ■>.- .    ^   - ...    •        .  -     *• 

T-      i-  ,1"         •!-'>-.■.■> 

•a  'ci  b 

Fiu.  Sli. — GRADt'Ai,  Lun'KiAcrio.\  oi-  A  Mvo.MA.  (X  S")  ilisim.i 
G.vn.  No.  12.522.  Path.  No.  92.3.3.  .■Vt  the  point.s  inilirated  li.v  a  the  churuct«'riNli<-  iii.viiiiiatinis  livsiu-  ^lill 
persists;  at  6  is  a  cross-section  of  a  inuscle-Vxindle  and  al  c  a  cross-swlion  of  an  imlividual  niiiscU'-lilnT.  d  is  a 
blood-vessel.  At  e  all  trace  of  the  muscle  has  disappcareil,  iiolhinK  Ikmmk  left  l)Ut  liyaline  material  and  (lie  outhiie 
of  hyaline  connective  tiss\ie.  .\t  /even  the  hxaline  li:i>  heen  replaced  li\  an  irremil;ir  space  tilleil  with  coanuhdeil 
fiviid. 

S.    M.,   aged    thii-t\'-f()Ui'.    admiltcd    .XoNciiibci-    17,    I'.X).");   discliiugcd    on    the 
twenty-fifth   day.     The    uterus   is    .•ipproxiiu.'ilcly    I.'!   cm.    in    diMiuctci-    mikI    is 


104 


MYo.MATA    OF    THK    ITKUIS. 


tilohular:  it  has  a  cystic  feel  and  contains  a  juicy-lookint;'  myoma.  It  is  free 
from  adhesions.  The  myoma  is  uniformly  semisohd  and  is  filled  with  small 
cystic  areas.      Kroni  the  cut  surface  a  straw-colored  tluid  esca])es. 

Micro.scopically,  the  myoma  shows  marked  hyaline  d(\<>;eneration.  AMiere 
the  cy.sts  occur,  there  are  clear  spaces  with  only  a  few  muscle-lihers  remaining. 
These  stand  out  clearly.  The  picture  is  one  of  a  myoma  undero-oing  hyaline 
transformation,  with  gradual  li(|Uefaction  (Fig.  82). 


Gyn.  No.  3349.     Path.  No.  610. 

L  i"(|  u  e  f  a  c  t  i  o  n     o  f     a     h  y  a  1  i  n  e     m  y  o  m  a  (Fig.    <S8). 
S.  Pv..  married,  aged  forty-eight,  white.     Admitted  February  26;   discharged 
March  2r).  IS')."). 

a 


a  - 


-# 


■% 


r; 


^i 


/»': 

-^ 


(T^Vv^-i^ 


Fig.  83. — Lhjukfikd  and  IIvaline  Arkas  in  a  Myoma.  (X  95  diain.) 
Gyn.  No.  3349.  Path.  No.  610.  At  the  points  indicated  by  n  transverse  or  longitudinal  sections  of  muscle- 
bundles  are  still  visible.  Scattered  throughout  the  field  are  dark  circular  or  irregular  clumps  of  hyaline,  particu- 
larly well  seen  at  b.  These  are  muscle-bundles  that  have  undergone  complete  hyaline  transformation.  The  lighter 
hyaline  matrix,  a.s  seen  at  c,  represents  what  remains  of  the  filjrous  structure.  In  the  center  of  the  picture  is  an 
irregular  cavity  (d),  lined  with  hyaline  tissue,  and  filled  with  a  granular  material — coagulated  serum.  .\I  e  are 
empty  spaces  from  which  all  trace  of  the  myoma  has  disappeared. 

This  picture  gives  in  detail  practically  all  stages  that  occur  when  a  myoma  undergoes  hyaline  degeneration. 


Path.  Xo.  GIO.  The  specimen  consists  of  an  enlargetl  uterus  with  both  tubes 
and  ovaries.  The  uterus  is  jx'ar-shaped  and  nieasui'es  lOx  12x10  cm.  An- 
teriorly, it  i.s  smooth  and  glistening;  posteriorly,  it  is  covered  with  a  few  iion- 


HYALIXE    AXD    CYSTIC    DEGKXKRATlOX.  105 

vuscular  adhesions.  On  the  anterior  surface  of  the  uterus  is  a  subperitoneal 
nodule,  1  cm.  in  diameter.  Situated  in  the  anterior  uterine  wall  i.s  a  sharply 
defined  globular  tumor,  9  cm.  in  diameter.  In  part  this  is  made  up  of  a  delicate 
meshwork  of  libers  running  in  all  directions,  but  th(>  greater  portion  consists  of 
a  jelly-like  material,  yellowish  in  color,  translucent,  and  from  the  cut  surface  of 
which  a  large  quantity  of  clear  fluid  escapes.  This  fluid  coagulates  on  exposure 
to  the  air.  The  entire  tumor  might  be  likencHJ  to  a  ball  of  ]o]\y  everywhere 
traversed  by  delicate  fibrilhe. 

Histologic  Elxamination. — The  large  nodule  in  the  tmterior  uterine  wall  is 
composed  of  non-striped  muscle-fibers  which  have  undergone  diffuse  hyaline 
degeneration,  the  individual  fibers  being  separated  from  one  another  by  hyaline 
material.  Where  the  tissue  appears  jelly-like  the  field  is  almost  colorless  (Fig- 
83),  but  a  fine  fibrillated  meshwork  can  be  made  out,  and  scattered  here  and 
there  throughout  this  colorless  material  are  little  islands  of  muscle-fibers  and 
man}^  delicate  blood-vessels.  In  other  portions  isolated  nmscle-fibers  can  be 
seen  and  the  tissue  also  contains  hyaline  droplets.  It  looks  as  if  the  muscle- 
fibers  had  first  undergone  hyaline  degeneration,  and  that  after  this  the  hyaline 
material  had  broken  up  into  clumps  and  had  disappeared,  leaving  a  fibrillat(>d 
network. 

C.  H.  I.  620.     Path.  No.  8827. 

Liquefaction    of    a    myoma   (Fig.  84) . 

E.  S.,  aged  thirty-five,  married,  white.  Admitted  May  25;  discharged 
June  24,  1905. 

Path.  No.  8827.  The  specimen  consists  of  a  nodular  myomatous  uterus, 
amputated  through  the  cervix,  and  of  a  fetus  at  about  the  second  month.  The 
uterus  itself  is  nodular  and  is  8x8.5x16  cm.  The  largest  myoma  is  apjiroxi- 
mately  11  cm.  in  diameter.  There  is  a  diffuse  myomatous  thickening  of  the 
uterine  walls. 

Histologic  Examination. — Sections  from  the  endometrium  show  the  usual 
appearance  of  pregnancy.  Those  from  the  myoma  show  typical  and  wide-spread 
hyaline  degeneration,  a  few  fibers  remaining  here  and  there  throughout  the  hya- 
line tissue.  Other  portions  have  gone  on  to  li([uefaetion  (Fig.  84).  \\  here  such 
changes  have  taken  place  almost  the  entire  field  is  filled  with  coagulated  serum. 
The  density  of  the  eosin  stain  depends  ui)on  llic  ainoimt  of  albumin  that  the 
fluid  contained.  The  fluid  is  di\idcd  off  into  little  comijartments  by  deli- 
cate strands  of  either  nuiscle-fibers  oi-  connective  tissue.  The  walls  of  the  cyst- 
spaces  are  devoid  of  endothelium. 

Gyn.  No.  3504],.     Path.  No.  719. 

M  a  r  k  e  d  h  y  a  1  i  n  e  a  n  d  c  y  s  t  i  c  d  e  g  e  n  e  r  a  t  i  o  n  o  f  a  n 
interstitial     u  t  e  i' i  n  e     in  y  o  in  a    (l''ig.    N5). 

M.  0.,  single,  aged  thirtw  coloi-ed.  .Vdmitted  May  11:  dischai'ged  .luiie  IS, 
1895. 


106 


MldMATA    OK    'I'llI':    ITKHl'S. 


Path.  No.  71*1.  The  s])c('iiii('n  consists  of  the  litems  with  the  appendages 
intact.  'Hie  uterus  measures  12  x  1(5x19  cm.  and  is  iVee  from  adhesions.  Pro- 
jecting from  the  lower  part  of  the  anterioi'  siu-face  are  two  small  pedunculated 
nodules,  the  larger  being  1x1.2x2  cm.  Situated  in  the  ])Osterior  wall  is  a 
tumor.  !l  X  lo  cm.  ( l-'ig.  So).    This  consists  of  one  large  cavit\'  traversed  by  fi])rous 


^S'S^ 


f; 


e   


■x' 


^m 


^ 


,  d 


/    •. 


y 


space 


^ 


Viv..  84. — I.iiji'i'.i'ACTioN  AND  Hyai.ini:  .Vhka^;  in  a  .Myoma.      (X  90  diam.) 

C.  H.  1.  <)20.  I'lith.  N(i.  S,S27.  Tlie  specimen  i.s  from  a  mynma  diiriiiK  the  early  months  of  pregnancy,  n  in- 
dicates the  usual  myomatovis  tissue.  In  the  upijer  part  of  the  field  are  cross-sections  of  l)\iiidles  of  swollen  muscle- 
fibers  ffc).  r  indicates  blood-vessels.  The  rest  of  the  field  is  comp(jse<l  of  albuminous  fluid  divided  off  into  compart- 
meats  by  delicate  cai)illaries,  as  indicated  at  d.  The  coagulated  fluid  in  the  various  comi)artments  differs  in  density 
of  staining.  This  depends  upon  the  amount  of  albmiiin  contained  in  the  fluid — the  more  albumin,  the  deeper 
the  stain.  At  e  the  albuminous  contents  are  abundant,  at  /  almost  nil,  a,s  the  fluid  stains  very  faintly.  The  lower 
border  of  the  section  is  a  small  segment  of  a  cyst-wall       It  is  totally  devtiid  of  an  endothelial  lining. 


trabeciihe,  which  ))artially  di\ide  it  into  se\-eral  smaller  ca^■ities.  filled  with  a 
yellowish,  transparent  lluid.  The  walls  of  the  ca\"ity  are  conqjosed  of  a  yellow- 
ish, cruml)ly  material.  The  outer  rim  of  the  tumor  is  still  intact  and  varies 
from  1  to  'A  cm.  in  thickness.     The  ajjix'iidages  are  normal. 


HVALIXK    AXI)    CYSTIC    DKC.EXF.RATIOX. 


10- 


Histologic  Examination. — The  tumor  is  composed  of  noii-stripcd  muscle- 
fibers  closely  packed  together.  The  tissue  lining  the  cyst-like  cavities  has 
undergone  complete  hyaline  transformation.  This  hyaline  material  in  some 
places  presents  a  homogeneous  appearance,  but   in  other  places  the  colorless 


Fig.  85. — Hyai.ink  Dkgkxkration   wriii   Liquef.\ctio.\   ok  an   Intkri*titiai.  I'tkhi.m;  .Myoma.     (J  nut.  siie.) 
Gyn.  No.  .3.504^.     Path.  No.  71i).     Occupying  the  fun(lu.<  is  a  myoma  9  x  I'.i  cm.     The  conter  of  this  consists 
of  one  large  cavity  lined  with  a  shaggy,  crumbly  material,  and  traversed  with  tr;jl)eciila'.     It  has  ooiitniiie<i  a  clear 
transparent  Huid.     The  appendages  are  normal,  and  the  uterine  cavity  hsis  in  no  way  l>een  encroached  upon. 
Histologic  examination  shows  that  the  inner  lining  of  the  dcgcncrale<l  m\iima  <-onsisls  of  hyahiie  material. 


mu.scle-fibcrs  are  still  xisible.  Here  and  tlicic  unaltered  niuscle-libers  can  still  be 
made  out.  The  hyaline  material  graduallN"  fades  a\\a\'  and  on  the  inner  surface 
of  the  cavities  almost  entirely  di.sa])])ears.  The  line  of  junction  between  the  de- 
generated and  unaltered  muscle-fibers  is  siimrplv  defined,  the  one  ending  abruptly 
where  the  other  begins.  The  caxity  foriiiatioii  in  this  case  is  due  to  hyaline 
degeneration  with  subse((uent  lii(uefaction.  At  no  |)oiiit  does  the  ('a\ity  show 
any  epithelial  or  endothelial  lining. 


108  MYOMATA    OF   THE    rTP:Rl"S. 

Gyn.  No.  7049.     Path.  No.  3318. 

M  a  r  k  v  cl  li  y  a  1  i  11  v  d  e  g  c  n  c  ration  and  1  i  (|  11  c  f  a  e  t  i  o  n 
of     a     large     myoma  (Fig.  86). 

A.  -M.,  married,  white,  aged  fifty-one.  Admitted  July  6:  discharged  August 
17.  1S09. 

Path.  No.  :VA\s.  The  specimen  consists  of  a  large  myomatous  uterus,  with 
intact  tubes  and  ovaries.  The  myomatous  mass  is  markedly  nodular,  being 
studded  with  mvriads  of  small  and  moderately  large  nodules.  The  tumor  meas- 
ures 23  X  25  X  31  cm.,  and  situated  in  a  cleft  on  its  upper  and  anterior  surface 
is  the  verv  small  uterus.  The  myoma  has  conseciuently  filled  the  ])elvis  and 
spread  out  the  folds  of  the  broad  ligament.  On  section,  it  is  found  that  almost 
the  entire  myomatous  mass  has  been  converted  into  a  huge  cavity  (Fig.  86), 
the  inner  surface  of  which  presents  a  shaggy  appearance.  Traver.sing  the  cavitj^ 
in  all  directions  ar(^  large  and  small  trabecuhr  that  hold  together  large  and  firm 
masses  m  the  centei-,  the  trabecuhe  .stretching  from  side  to  side.  The  shaggy 
masses  lining  the  walls  of  the  cavity  are  whitish  yellow  in  color.  The  general 
impression  gained  is  that  the  softened  portions  of  the  myoma  have  melted  away, 
leaving  the  more  resistant  ])ortions,  which  remain  as  trabecuhr.  The  Huid 
filling  the  cavity  is  somewhat  turl)id  and  of  a  greenish-brown  color. 

Histologic  Examination. — The  outer  i)ortions  of  the  walls  of  the  large  and 
cystic  myoma  consist  of  typical  myomatous  tissue.  The  shaggy  inner  surface 
and  the  trabecuhe  re])resent  nothing  more  than  myomatous  tissue  that  has 
undergone  complete  hyaline  degeneration.  This  ti.ssue  is  totally  devoid  of  nuclei 
of  any  kind. 

San.  1925.     Path.  No.  8838. 

A  1  a  r  g  e  m  u  1  t  i  n  o  d  u  1  a  r  m  y  0  m  a  t  0  u  s  u  t  e  r  u  s  wit  h  a 
h  u  g  e     subperitoneal     and     cystic    m  y  o  m  a    (Fig.  87). 

G.  S.  W.,  aged  thirty-eight,  married,  white.  Admitted  May  8;  discharged 
June  13,  1905. 

Path.  No.  8838.  The  specimen  consists  of  the  uterus,  with  many  myomata, 
and  the  appendages.  The  tiunor  weighed  twenty  ])ounds.  The  uterus  has  been 
crowded  down  between  two  myomata.  One  is  irregularly  kidney-shajx'd, 
17  cm.  in  length:  the  other  sj)rings  from  the  ])osteri()r  surface  of  the  uterus,  and 
is  15  cm.  in  length.  Scattered  throughout  the  uterus  are  numerous  peduncu- 
lated, interstitial,  and  partially  submucous  myomata.  The  chief  interest  is 
centered  in  the  cystic  pedunculated  myoma,  30  cm.  in  its  longest  diameter 
(Fig.  87).  This  is  attached  to  the  anterior  and  right  side  of  the  uterus  by  a  short 
pedicle,  6  cm.  in  breadth.  This  tumor  is  covered  with  omentum,  which  is 
greatly  thinned  out .  ( )n  section,  it  is  found  to  consist  of  myomatous  tissue  in  the 
outlying  portion:  in  the  central  portion  is  a  gelatinous-like  tissue,  with  trabecuhe 
running  through  and  giving  rise  to  many  large  and  small  cystic  spaces.  In  the 
center  of  the  tumor  is  an  oval  cystic  space,  8x10  cm.     It  has  a  .smooth  lining 


Fig    86-M.ss,vk  Hvaiin,:  1)k,;kn,:u  m  h.n  an..  I.u„  ,:.  a.,  .on  .m-  a   1.vu..k  r.KU.s.:  Mvoma.     .iA  nat.  Mre.  > 
Gyn.  No.  7049.     Path.  No.  331S.      11...  ...„..m   „K.u.suro.l  23  x  W  x  31  <•....     Situa..-!  in  u  cU-f.  ....  ...s  ,.,.,.cr 

and  anterior  surface  was  .he  ve,y  .....all  u,...us.      Al .st  .he  en.ire  ....nor  ha.s  ..o.-..  conv..,-..-..  ....o  ••"«;  >;j  J"  ;«;   " 

The  walls  are  ,.o„.,„.se.l  of  typical  ...vo.na.ous  .i.ssue.  well  see.,  at  a.     Near  .he  walls  are  er..ss-..er...  ...m  of  ,  ,>o- 

n'ai:;  ttsi.e  that'has  undergone  hyaline  change.     This  is  elearly  seen  at  /,.     The  ee...ral  ,.or,...n  of  < J--;  ^  '» 
partly  filled  by  a  shaggy  degenerated  .na.erial.  held  in  plaee  l.y  trabeeula.  ex.e...l.ng  to    he  """;■-'",.  J;   '^      ,     ^ 

finer  trabecular  are  seen  at  c.     At  d  is  a  large  space  where  con.ple.e  d.s.n.egr... ha-    aken  place.     I  h        '       >  '     « 

the  tumor  was  somewhat  turbid  and  gree.ush  brown  in  color.     TI.e  shaggy  .n..cr  wall.  a..d  the  .naxM  s  .n  .lu  . ,  n- 
ter  consisted  of  hyaline  material  totally  devoid  of  nnclc. 

10'.) 


110  MVO.MATA    OF    THK    UTERUS. 

aiul  in  sonic  portions  contains  a  clear  fluitl:  in  others,  chocolate-colored  clots, 


e-'ifJ^i. 


Fig.  87. — A  Cystic  Subi-kritoxeai-  Pkdlnculatku  Myoma.  (^  nat.  size.) 
San.  No.  192.5.  Path.  No.  8838.  To  the  right  is  the  enlarged  and  myomatous  uterus.  To  the  left  a  large 
and  somewhat  flattened  cystic  m.voma,  .30  cm.  in  its  longest  diameter.  This  is  attached  to  the  uterus  by  a  short 
pedicle,  6  cm.  in  breadth.  Over  the  greater  part  of  its  convexity  it  is  covered  with  dense  omental  adhesions. 
The  tumor,  to  a  great  extent,  has  been  converted  into  large  and  small  cystic  spaces.  Between  the  points  a  and 
a'  the  delicate  cystic  formation  with  fine  trabecular  is  particularly  well  seen.  Most  of  the  smaller  c.vsts  were  filled 
with  clear  fluid.  The  largest  cyst  is  8  -x  10  cm.  and  has  a  smooth  lining.  It  was  partially  filled  with  clear  fluid, 
I)artially  with  clots.  The  cyst  c  contained  remnants  of  old  blood.  Sections  from  various  parts  of  the  tumor 
show  marked  hyaline  degeneration  with  liquefaction.  Clinging  to  the  large  cysts  are  partly  organized  clots  and 
old  blood-pigment.     There  is  no  evidence  of  entlothelium. 

evidently  the  remains  of  old  hemorrhages.     There  is  also  another  oval  cystic 
space,  9  cm.  in  length  and  traversed  l)y  traljeciihe   ]-)resenting  a  homogeneous 


HYALINE    AND    CYSTIC    DEGKXHKATIOX. 


Ill 


Fig   88.  -A  Mn.iii.oci  i.au  Cvsrn 
Cvn    No   888"       Path    N..    5072       The  ut.-ru.  is  r.-lntivoly  M..,,n:.l  in  size.      Mot).  t„l..-s  un.l  tl,.-  l.-ft  -vary  :ire 

no.JS';;^: p^^i.,;;:;::.  t:;.t.  ..v..  is .•>•-  ..,.u.  rn.... ....  -;;;-•;;;:::;  -;.:;^:r;;;;:Hi::: 

.ovulated  cystic  tun..,-.     This  .k.  ^^^^;^.^^^'^^y X:'::X^''v^^^^  ^^ 

In  such  cases  there  is  great  (iaiiRer  of  injury  to  the  ureters.      lAen  ii.ur  ui.    i 
at  first  supposed  to  be  an  ovarian  .-yst.      Kor  the  tu.nor  on  .section  .see  !•  .g.  H.». 


112  MYOMATA    OK    THK    ITKIU'S. 

ai)])('amiK'('.  It  is  evidently  filled  with  a  good  deal  of  old  blood.  These  two 
cystic  spaces  arc  very  unusual.  l)ut  the  outlying  semisolid  and  cystic  portion 
is  characteristic  of  any  case  of  advanced  hyaline  transformation  of  a  myoma. 

Histologic  I'^xamination. — The  edematous,  cystic  areas  are  the  i-esult  of  a 
iiiai-ked  h\-aline  t raiistoi'iiiation,  with  sul)se((ueiil  rK|uefaetion.  The  tissue  im- 
medialelv  around  the  hlood- vessels  has  undergone  almost  complete  hyaline  trans- 
formation. We  have,  also,  large  areas,  absolutely  devoid  of  cells  and  later  this 
hyaline  material  has  become  almost  transparent  and  entirely  disappears.  The 
line  of  hyaline  transformation  is  in  many  places  very  sharply  defined.  In  some 
places  throughout  the  hyaline  material  we  have  deposits  of  yellowish  pigment,  in 
all  probability  the  result  of  old  hemorrhag(>s.  Sections  from  one  of  the  cystic 
spaces  partially  filled  witli  blood  show  that  we  have  here  in  the  Avails  also  a  great 
deal  of  hyaline  transformation.  Clinging  to  the  wall  is  fibrin,  here  and  there 
aggregations  of  small  round  cells,  and  occasionally  polymorphonuclear  leu- 
kocvtes.  Many  of  the  leukocytes  have  a  brownish  tinge,  showing  that  they  are 
rather  old  and  have  probably  imbibed  old  blood- pigment.  Clinging  to  the  inner 
surface  of  one  of  the  cysts  is  blood,  which  is  fairly  well  preserved. 

Gyn.  No.  8882.     Path.  No.  5072. 

A  large  m  u  1  t  i  1  0  c  u  1  a  r  cystic  m  y  o  m  a  d  e  v  e  1  o  p  i  n  g 
f  r  o  m  the  p  o  s  t  e  r  i  o  r  s  u  r  f  a  c  e  o  f  t  h  e  u  t  e  r  u  s  (Figs.  88  and 
89). 

A.  B.,  aged  thirty,  white,  married.  Admitted  June  25:  discharged  July  19, 
1901.  She  has  been  married  eleven  years,  has  had  three  children,  the  youngest 
now  twenty  months  old.  The  labors  were  easy  and  there  were  no  complications. 
Fourteen  years  ago  she  first  noticed  a  small  tumor  in  the  abdomen.  This  has 
grown  steadily  since  then,  but  has  given  rise  to  ncj  symptoms. 

Operation.  Panhysterectomy.  On  section  of  the  abdomen  the  uterus  was 
found  resting  on  the  top  of  a  cystic  mass.  This  mass  was  su])posed  to  be  an 
ovarian  cyst  and  not  until  it  ruptured  was  the  true  diagnosis  arrived  at.  Enu- 
cleation was  carried  out  in  the  usual  manner  from  left  to  right.  The  procedure 
took  a  good  deal  of  time,  owing  to  the  dense  i)elvic  adhesions  and  to  free  oozing 
from  the  vaginal  veins.     Ther(>  was  a  hydro-ureter  on  the  right  side. 

Path.  No.  5072.  The  specimen  consists  of  the  uterus,  which  is  but  little 
altered,  and  of  a  large  tumor,  which  has  apparently  developed  in  the  posterior 
wall.     This  tumor  measures  9  x  20  x  31  cm.,  is  lobulated,  cystic,  and  is  very  sug- 


Fi<;.  89. — A  Lah<;k  Cy.stic  Myoma  Growing  from  rm:  Postkrior  Surface  of  the  Utkrus. 

Gyn.  No.  8882.  Path.  No.  5072.  The  picture  represents  a  longitudinal  section  of  the  tumor  seen  in  Fig.  88. 
a  indicates  the  uterine  cavity,  which  is  normal.  Springing  from  the  posterior  wall  of  the  uterus  is  the  large  multi- 
cystic  myoma,  9  x  20  x  31  cm.  Covering  the  outer  surface  is  a  mantle  of  muscular  tissue  (6).  The  upper  part  of 
the  tumor  contains  large  cystic  spaces  with  secondary  recesses  opening  into  them.  The  lower  half  presents  a 
spongy  appearance,  due  to  the  presence  of  many  small  cysts  embedded  in  the  rarefied  tissue. 

Histologic  examination  shows  that  nearly  the  entire  central  i^ortion  of  the  tumor  is  devoid  of  nuclei.  The  solid 
tissue  is  much  r:iretied  or  "threadbare,"  and  the  cysts  are  spaces  devoid  of  any  epithelial  or  endothelial  lining. 


^^  X:., 


/ 


^:;;  •^ 


:^ 


Fig.  89. 


113 


114 


^n■().MA■l■A    OK     11  IK    UTKRIS. 


gcstivc  of  an  oRliiiary  niultilocular  ovarian  cyst  ( Fi*!;.  SS).  On  section  (Fig.  89) 
the  upper  ])art  of  the  tumor  is  foniul  to  he  made  uj)  of  hirgc  cysts  with  numerous 
recesses  opcninu-  into  them.     Tlicsc  cysts  appear  to  he  filled  with  clear  fluid. 


Fig.  90. — A  Large  Slhi'erito.\k.\i.  Cv.stic  Myo.ma.     (i  nat.  size.) 
Gyn.  No.  6432.     Path.  No.  2661       Springing  from  the  fundus  is  a  partially  pedunculated  cystic  tumor,  16  x  27 
X  30  cm.     The  fundus  itself  is  somewhat  enlarged,  from  the  presence  of  myomatous  nodules,     lioth  tubes  and  the 
left  ovary  are  normal.     The  right  ovary  contains  a  small  dermoid  cyst.     For  the  appearance  of  the  uterus  on  sec- 
tion see  Fig.  91. 


The  lower  half  of  tlie  tumor  is  made  up  of  a  s|)on<iy  material  containing  numerous 
small  C3'8ts  in  it.s  me.shes.  Covering  the  entire  outer  surface  is  a  mantle  of  myo- 
matous tissue,  in  most  places  reaching  1  cm.  in  thickness. 


HYALINE    AND    CYSTIC    D?:GENERATI0N. 


115 


Fig.  fll. — A  Cystic  Myoma. 
Gyn.  No.  64.32.  Path.  No.  2001.  (For  the  geiicrul  appejinince  of  the  tumor  .sco  FIr.  ilO.I  The  M'ction  has 
been  cut  longitudinally  through  the  tumor.  The  upper  part  of  the  tumor  han  heen  converte.!  into  a  large  cystic 
cavity  with  walls  from  1  to  .3  mm.  thick.  The  inner  surface  is  smooth  an.l  on  the  right  are  numerous  traheculae. 
pas.sing  from  the  outer  thin  wall  to  the  soli.l  l.orlion  of  th<;  tumor.  lliese  Iral.ecuhe  .-arry  hlu,..l-vessel8.  A 
large  wedge  of  the  solid  portion  of  the  tumor  has  undergone  complete  iiyahnc  degeneration,  hut  in  the  lower  part 
the  typical  myomatous  tissue  still  persists.  1  h.'  uteiine  cavity  it.self  is  normal.  There  was  no  epithelial  nor 
endothelial  lining  to  the  cyst. 


116  MVOMATA    OF   TllH    ITKUl'S. 

Histologic  Examination. — The  outor  portions  of  the  tumor  present  the  usual 
myomatous  appearance.  The  central  ]X)rtion  consists  of  tissue  that  has  under- 
gone hyaline  degeneration  or  is  entirely  devoid  of  nuclei.  It  is  gradually  be- 
coming rarefied  and  the  empty  spaces  are  totally  devoid  of  any  endothelial 
linhig.  This  is  the  most  remarkable  cystic  degeneration  in  a  myoma  that  we 
have  ever  noted. 

Gyn.  No.  6432.     Path.  No.  2661. 

A  1  a  r  g  e  c  y  s  t  i  c  m  y  o  m  a  s  p  r  i  n  g  i  n  g  f  r  o  m  the  f  u  n  d  u  s 
of  t  h  (>  u  t  e  r  u  s   (Figs.  90  and  91). 

A.  B.,  single,  aged  forty-four,  white.  Admitted  October  18;  discharged 
November  17,  1898. 

Path.  No.  2601.  The  specimen  consists  of  the  uterus,  attached  to  which  is  a 
large  tumor,  lx)th  tubes,  the  left  ovary,  and  a  dermoid  cyst  of  the  right  ovary 
(Fig.  90).  The  uterus  proper  is  relatively  small,  measuring  5x6x6  cm. 
Springing  from  the  fundus  is  a  large  pedunculated  tumor,  16  x  27  x  30  cm. 
On  the  posterior  surface  of  the  tumor  is  a  groove  corresponding  to  the  promi- 
nence of  the  sacrum.  The  surface  of  the  tumor  is  smooth  and  glistening,  and 
traversed  by  numerous  blood-vessels.  It  is  fluctuant  and  its  walls  are  appar- 
ently thin.  The  tumor  is  attached  to  the  fundus  by  a  broad  pedicle,  6  cm.  in 
diameter.  Springing  from  the  posterior  surface  of  the  large  tumor  on  the  left 
side  are  two  nodules.  The  large  myoma,  on  section,  is  found  to  be  composed 
of  two  portions,  one  cystic,  the  other  solid  (Fig.  91).  The  upper  part  forms 
one  large  cavity,  with  numerous  trabecukr  extending  to  the  wall  of  the  solid 
portion  of  the  tumor.  The  wall  itself  is  composed  of  myomatous  tissue  of 
varying  thickness.  Fully  one-third  of  the  solid  portion  of  the  tumor  has 
undergone  complete  hyaline  degeneration,  as  indicated  in  the  figure. 

Histologic  Examination. — The  walls  of  the  large  cystic  tumor  present  smooth 
inner  and  outer  surfaces,  the  former  having  no  special  cell  lining.  The  walls 
consist  of  large  spindle-shaped  fibers  that  run  more  or  less  parallel  to  the  circum- 
ference, but  in  some  places  hiterlace.  There  is  considerable  fibrillation  of  the 
tissue,  which  is  poor  in  cells  and  is  quite  edematous.  The  picture  is  a  very 
unusual  one. 

Gyn.  No.  4485.     Path.  No.  1245. 
A    m  u  1  t  i  c  y  s  t  i  c    u  t  e  r  i  n  e    m  y  o  m  a     (Fig.  92). 


Fig.  92. — A  Large  Multicystic  Myoma.  (;'.  nat.  size.) 
Gyn.  No.  4485.  Path.  No.  1245.  This  tumor  measured  19  cm.  in  diameter,  was  lobulated,  densely  adherent, 
and  attached  to  the  upper  surface  of  the  uterus  by  a  twisted  pedicle.  Bulging  from  the  surface  are  several  large 
cystic  spaces.  The  cysts  are  large  and  small,  and  even  the  smallest  have  smooth  walls.  Clinging  to  the  inner  sur- 
face of  some  of  the  cysts  is  old  blof>d.  The  solid  portion  of  the  tumor  consists  of  myomatous  tissue,  which  has  in 
places  undergone  marked  hyaline  degeneration.     The  cysts  are  devoid  of  any  epithelial  or  endothelial  lining. 


Fig.  92. 


117 


118  MVOMATA    OF    THE    UTERTS. 

A.  .1..  married,  ai^cd  forty-seven,  white.  Admitted  .Iviiie  25:  discharged 
August  2,  1S9().  The  patient  had  one  child,  twenty-three  years  ago.  She  first 
noticed  an  abdominal  enlargement  ahovU  six  months  ago.  The  increase  in  size 
has  heen  gradual. 

At  the  operation  the  cystic  myoma  had  a  twisted  ))edicl(>  and  there  were  dense 
adhesions  between  the  tumor  and  the  anterior  abdominal  wall.  The  tubes  and 
ovaries  were  adherent  to  the  ])elvic  fioor. 

Path.  Xo.  1245.  The  specimen  consists  of  the  uterus  with  its  appendages 
and  of  a  large  tumor.  The  uterus  is  a])proxiniately  globular,  and  averages  8  cm. 
in  diameter.  It  is  covered  with  a  few  adhesions.  The  walls  are  thickened,  and 
contain  two  small  myomatous  nodules.  Occupying  the  fundus  is  a  tumor,  5  cm. 
in  diameter,  which  is  becoming  cystic.  The  large  tumor  (Fig.  92),  springing 
from  the  ii))per  surface  of  the  uterus  where  it  joins  the  right  tube,  is  irregular  in 
.shape  ami  avei'ages  19  cm.  in  diameter.  Projecting  from  its  surface  are  rmmer- 
ous  bosses  and  two  pedunculated  cysts,  8  and  9  cm.  in  diameter  respectively. 
The  large  cyst  has  delicate  walls.  These,  OA'er  an  area  4  nun.,  have  undergone 
partial  rupture,  some  of  the  layers  having  given  way.  The  tumor  is  covered 
with  dense  adhesions,  some  of  which  contain  adipose  tissue.  The  walls  of  the 
tumor  vary  from  2  to  4  nun.  in  thickness.  One  smaller  cyst  is  hemorrhagic  and 
there  are  numerous  adhesions  on  the  under  surface  of  the  tumoi-.  The  cysts 
have  smooth  inner  surfaces. 

Histologic  Examination. — The  solid  ])art  of  the  large  tumor  consists  of  non- 
striped  muscle-fibers,  and  between  the  nmscle-bundles  are  wide  bands  of  con- 
nective tissue  which  have  undergone  hyaline  degeneration.  The  tumor  has  an 
abundant  l)lood-sup])ly,  but  many  of  its  vessels  are  becoming  ol)literated  and 
others  are  filled  with  recent  or  partially  organized  thrombi.  The  walls  of  the 
cyst  projecting  from  the  surface  of  the  large  tumor  are  likewise  composed  of  non- 
.striped  muscl(>-fil)ers.  There  is  no  evidence  at  any  jioint  of  an  epithelial  or  en- 
dothelial lining. 

Gyn.  No.  13625.     Path.  No.  11651. 

A    V  e  r  y    1  a  r  g  e    c  y  s  t  i  c    m  y  o  m  a    ( Fig.  93). 

A.  N.,  married,  white,  aged  forty-eight.  Admitted  March  1;  discharged 
March  29,  1907.  Four  years  ago  the  patient  began  to  notice  a  uniform  en- 
largement in  the  abdomen.  This  increase  in  size  has  been  gi'adual.  The  ])a- 
tient  states  that  the  girth  of  the  abdomen  increases  during  her  menstrual  ju'riod. 

The  tumor  was  densely  adherent  to  the  omentum  and  from  it  the  greater 
part  of  the  nourishment  came. 

Path.  No.  11651.  The  specimen  consists  of  the  uterus,  attached  to  which  is 
a  large  cy.stic  myomatous  mass,  the  whole  measuring  approximately  16  x  35  x  50 
cm.  (Fig.  93).  The  uterus,  which  has  been  am])utated  through  the'cervix, 
measures ajjproximately  7x11  cm.  It  is  multinodular,  containing  subperitoneal 
and  interstitial  myomata.  The  main  tumor  springing  from  the  fundus  measures 
approximately  16  x  35  x  39  cm.     The  surface  of  the  tumor  is  moderately  smooth, 


KiG.  93.— A  Cystic  Myoma  \Vi:i<-..iin.;  39  Pounds  anm,  Cm.sii.v  Hisimimin..  a  Mi  i.tii.o.ti.ar  Ovarian  I  ^c 

(J  nat.  size.) 
Gyn  No  13625.  Path.  No.  1  ItuA.  In  the  Ul)|«-r  part  of  the  picliiro  a  cross-sort  ion  ..f  the  uterii.-*  is  seen.  It 
contains  one  interstitial  and  one  snhperitoneal  no.liile.  .\tta<-h.Ml  t..  the  si.le  ..f  the  viterus  is  a  very  larRe  nnilti- 
locular  cystic  myoma.  At  the  points  iiulicato.l  hy  <i  tlie  myomatous  arranKemeiit  is  still  clearly  seen.  I  he  small 
cysts  have  smooth  walls,  and  were  filled  with  clear  flui.l.  The  large  cyst  with  its  secomlary  hernial  project  inn  (/.) 
has  very  thin  walls,  so  thin  that  in  the  vicinity  of  r  light  was  easily  transmitte.1.  The  large  cyst  was  also  hlled 
with  clear  fluid.     The  outer  surface  of  the  cyst  was  covered  with  many  ..mental  adhesions 

119 


120 


MVO.MATA    OF    TIIK    I'TKHl'S. 


but  toward  the  iipjuT  part  anterior]}-  is  a  hand  of  omentum  approximately  10 
cm.  in  length  and  o  em.  in  width.  At  otliei'  jxjint.s  over  it.s  .surface  there  are  also 
omental  adhesions.  (.)ne  large  vein  in  the  omental  atlhesions  is  fully  8  mm.  in 
diameter  and  others  noted  at  operation  were  at  least  o  nmi. 

On  section,  the  large  cj^stic  mass  is  found  to  be  filled  with  a  moderately  clear 
straw-colored  fluid.  The  large  cystic  space  measures  api)roximately  25  cm.  in 
diameter.  The  walls  are  perfectly  smooth  and  about  the  thickness  of  parch- 
ment. Large  l)lood- vessels  can  be  seen  coursing  in  the  walls  in  this  cyst.  Pro- 
jecting from  the  large  cyst  is  a  secondary  hernial  cyst.     The  middle  portion  of 

the  tvmior  is  made  up  of  moder- 
ately firm  whorls  of  myomatous 
tissue,  l)ut  here  also  cystic 
spaces  are  in  evidence,  the 
largest  cyst  measuring  l.o  cm. 
in  diameter.  All  these  spaces 
have  smooth  imier  linings  and 
contain  clear  fiuid. 

Histologic  Examination. — 
Sections  taken  from  the  more 
solid  portions  of  the  large  tumor 
show  that  it  is  made  up  of  my- 
omatous tissue,  in  places  mod- 
erately well  preserved.  In  most 
instances,  however,  there  is 
rather  extensive  hyaline  degen- 
eration. Sections  taken  from 
those  areas  which  macroscopi- 
cally  have  a  soft  and  gelatinous 
appearance  show  tvpical  lique- 

Fio.  94. — A  Cystic  Utkrixk  Myo.ma.  "" 

r.   H.  I.  F.  Path.  No.  6046.     In  this  case  there  was    a  factioU       of       the       mUSClc-fiberS. 

strang\ilated  umbilical  hernia.  Filling  the  pelvis  was  the  pro-  Jjj^  SOlUC  DlaCCS  "X  fcW  Cclls  are 
jection  a,  and  it  was  necessary  to  completely  sever  the  cervix 

before  this  could  be  dislodged.     A  large  part  of  the  main  tumor  Still    modcratcly   WCll    prCSCrVCd. 

M?n''.r^rHrr.'r'1°^r7*'r-'"^T'^'f'°^"'""""     Ii^  other  places  there  has  been 

tion  was  found  to  be  hned  with  hyaline  material.  t 

complete  disintegration,  only  a 
few  swollen  cells  or  shadows  of  cells  remaining.  Sections  taken  through  the 
edge  of  the  large  cystic  space  show  that  it  is  lined  with  typical  myomatous 
tissue.  No  endothelial  lining  can  be  noted.  This  is  one  of  the  most  pro- 
nounced examples  of  a  cystic  myoma  that  we  have  ever  encountered. 


C.  H.  I.  F.     Path.  No.  6046. 
S  t  r  a  n  g  u  1  a  t  e  d   u  m  b  i  1  i  c  a  1    h  e  r  n  i  a    and 
m  y  o  m  a     w  i  t  h     a     ]>  o  r  t  i  o  n     i  n  c  a  r  c  e  rated 
1)4). 


(Fit 


a    large    cystic 
in      the     pelvis 


HYALIXE    AND    CYSTIC    DKGEXKRATK  )X. 


121 


F.,  about  forty-five  years  of  lu^v,  was  seen  in  consultation  with  Dr.  A.  Trego 
Shertzer  and  admitted  August  10,  1902.  She  had  had  an  abdominal  tumor  for 
a  long  period.  She  came  to  the  hospital  hurriedly  on  account  of  a  strangulated 
umbilical  hcn-nia.  The  tissues  in  the  hernial  sac  were  almost  bluish  black.  After 
removal  of  a  wide  area  at  theuml)ilicusan  attempt  was  made  to  deliver  the  tumor. 
This  was  exceedingly  difficult,  because  a  large  portion  of  it  was  wedged  in  the 
pelvis.  Finally,  after  using  a  good  deal  of  traction,  we  were  able  to  expose  the 
tumor  and  amputate  through  the  cervix.  It  then  became  feasible  to  remove 
the  pelvic  portion.     The  patient  made  an  excellent  recovery. 

The  uterine  tumor  measures  22.5  x  20  cm.  Its  central  ])ortion  over  a  wide 
area,  as  indicated  in  Fig.  94,  has  undergone  complete  cystic  transformation. 
The  cystic  transformation  on  microscopic  examination  was  found  to  be  due  to 
hyaline  transformation,  with  subsequent  liquefaction. 


Gyn.  No.  13423.     Path.  No.  10677. 

Extensive    cystic    degeneration     of     an     interstitial 
uterine  myoma   (Figs.    95   and   96). 

H.  M.,  aged  forty-one,  white,  married.     Admitted  December  4,  190G;  dis- 
charged January  17,  1907.     The  patient  made  a  perfect  recovery. 

Path.  No.  10677.  The  specimen  consists  of  a  large  myomatous  uterus.  The 
uterus  itself  has  been  opened 
posteriorly.  It  is  15  cm.  in 
length,  8  cm.  in  breadth  (Fig. 
95).  The  uterine  walls  show  a 
considerable  thickening,  reach- 
ing 3  cm.  in  thickness  in  the 
upper  portion.  Occupying  the 
anterior  wall  is  a  growth  11  cm. 
in  diameter.  This,  on  section, 
is  cystic,  and  at  first  sight 
bears  a  striking  resemblance  to 
a  heart  (Fig.  96).  Its  walls 
vary  from  0.5  to  2.5  cm.  in 
liiickness.  Its  inner  surface  is 
smooth  and  glistening.  Its 
walls  contain  numerous  depres- 
sions and  smooth,  dome-like  section  see  Fig.  ot;. 
elevations;  and  stretching  from 

depression  to  depression  are  little  smooth  bands  which  are  rounded  imd  Ix'ai- 
considerable  resemblance  to  th(>  columnn'  caniea'.  'I'he  depressions  soiiictiines 
extend  for  at  least  2  cm.  into  the  ilcplli.  At  h.  on  the  anterior  surface,  is  a 
cyst  2  cm.  in  diameter,  with  smooth  walls.  This  cystic  sj)ace  was  tillctl  with 
clear  stra^v-colored  fluid,  which  did  not  coagulate  on  exposure. 


Fio.     95. — A     Cystic     Miu.\i.v.     Ui:cLiii.\o     the     .\ntkhioii 

Utkkine  Wall. 

Gyn.   No.    13423.     Path.    No.   10)77.     ProjectinR  int..  ilu> 

uterine  cavity  from  the  anterior  wall  i.s  a  glolnilar  tuiimr.      'I"hi' 

appendages  are  normal.      Fur  the  appearance  of  (lie  utniis  on 


122 


MYO.MATA    OF   THK    ITKRl'S. 


llistoloiiic  I^xainiiiatioii.  Sections  tVoiu  the  uterine  wall  show  undoubted 
beginning  adenoinyonia.  Sections  from  the  growth  in  the  waU  of  the  uterus 
show  that  it  is  coin])osed  of  myomatous  tissue.  The  musele-tibers  are  closely 
packed  together  and  at  first  sight  strongly  suggest  sarcoma.  The  individual 
cells.  howe\-er.  are  perfect  1\' sinoot h  and  the  muscle-fibers  ai'e  I'egulai'ly  arnuiged. 
Here  and  there  are  faint  evidences  of  li(|Uefaction.     The  muscle  ends  aljruptly  at 


Fig.  96. — A  Cystic  Myoma  with  a  Cavity  Rkskmblix(;  Somkwiiat  thk  Interior  of  a  Heart.  (?  nat.  size.) 
Gyn.  No.  1.342.3.  Path.  No.  10677.  For  the  general  relations  of  the  pelvic  organs  see  Fig.  95.  Occupying 
the  anterior  uterine  wall  is  a  myoma  11  cm.  in  diameter.  Its  line  of  junction  with  the  uterine  muscle  is  indicated 
by  a.  The  entire  center  of  the  tumor  is  cystic.  The  inner  surface  is  smooth  and  glistening,  but  there  are  numerous 
recesses  corresponding  to  dome-like  elevations,  and  stretching  across  the  depressions  are  rounded  trabeculsc  resem- 
bling columna;  carnece.  6  is  a  small  cyst  with  clear  contents.  The  cyst  was  filled  with  a  straw-colored  fluid  that  co- 
agulated on  exposure  to  the  air.  The  walls  of  the  tumor  show  some  hyaline  degeneration,  but  the  inner  surface 
is  lined  with  muscle-fibers.     There  is  no  evidence  of  any  endothelial  lining. 


the  inner  surface  of  the  cyst.  The  inner  .surface  is  also  lined  with  muscle-fibers, 
wiiich  lie  parallel  to  the  cyst  cavity  and  form  a  layer  of  cells  at  least  three  to  six 
deep.  We  expected  to  find  a  hyaline  imiei'  lining,  but  this  is  absent  on  the 
inner  surface,  a  most  unusual  picture  where  large  cysts  are  associated  with  uterine 
myomata.  This  is  the  only  myoma  in  which  we  have  found  such  an  appearance 
due  to  hyaline  degeneration. 


hyalixp:  and  cystic  degexeratiox. 


123 


i  n    Part 


,^ap»  gg*^^ 


Gyn.  No.  3 113.     Path.  No.  487. 

Cystic    8  p  a  cos    i  n    a    Al  y  o  ni  a    A  p  p  a  r  cull  y    d  u 
to  Dilatation  of  L  y  ni  p  h  -  c  h  a  n  n  c  1  s   (Fig.  97). 

A.  V.  G.,  married,  ag(d  fifty-two.     Admitted  October  16;   di.schargcd  De- 
cember 6,  1894. 

Path.  No.  487.  The  specimen  con.sists  of  a  large  globular  tumor,  in  the 
upper  portion  of  which  the  uterus  is  situated.  Both  tubes  and  ovaries  were  in- 
tact. The  tumor  is  approximately  circular,  25  cm.  in  diameter.  Along  its  lower 
and  anterior  surface  are  five  ill-defined  bosses,  the  largest  of  which  is  3.5  x  5  x  S 
cm.  The  tumor  is  whitish  red  in  color,  smooth,  glistening  and  covered  with 
peritoneum.  On  the  anterior  surface  of  the  tumor  is  a  piece  of  l)la{lder  mucosa, 
3x6  cm.  On  palpation  the  tumor  is  firm  tmd  yielding,  giving  a  faint  sensation 
of  fluctuation.  On  section,  it  is  whitish  in  color  and 
presents  a  finely  striated  appearance.  Scattered 
everywhere  throughout  the  tumor  are  sinuses  (Fig. 
97),  the  largest  of  which  is  1.2  cm.  in  diameter. 
These  have  smooth  walls  and  communicate  Avith 
numerous  smaller  ones.  They  contain  a  sercnis-like 
fluid.  Some,  however,  are  filled  with  dark-red  blood. 
Most  of  these  sinuses  appear  to  be  lymphatic  in  origin. 
On  section,  the  entire  tumor  mass, is  found  to  spring 
from  the  posterior  uterine  wall.  It  is  interstitial 
and  has  an  outer  covering  of  muscle  averaging  2 
mm.  in  thickness.  The  posterior  wall  of  the  uterus  is 
filled  witli  sinuses  similar  to  those  noted  in  the  tumor. 

Histologic  Examination. — The  uterine  muscle 
just  beneath  the  mucosa  appears  to  be  perfectly 
normal.  In  other  placets  it  contains  numerous  small 
empty  spaces,  some  of  which  lia\'e  an  endothelial 
lining.  These  are  pr()l)al)ly  lym])h-spaces.  The 
large  tumor  situated  in  the  posterior  wall  is  comj)()sed 

of  non-strij)ed  muscle-fibers  and  shows  diffuse^  hyaline  degeneration.  In  some 
places  this  hyaline  degeneration  is  so  mai-ked  that  the  inuscle-l)undles  ai)pear 
as  small  islands  in  the  hyaline  material.  Thei'e  arc  many  recent  hemorrhages, 
which  are  chiefly  confined  to  the  hyaline  aivas.  In  some  places  the  tumor  is 
edematous.  Tiie  blood-vessels  are  moderate  in  numbei'.  the  veins  pi-edominating. 
Scattered  everywhere  throughout  the  tumoi'  are  huge  and  small  empty  s))aces. 
some  with,  others  without  an  endothelial  lining.  .\s  the  blood  in  the  arteries 
and  veins  has  been  well  jHVserved  in  Miiller's  Huid  and  as  thes(>  spaces  are  com- 
paratively free  fi'om  bh)()d,  we  aiv  incHiicd  to  believe  that  ihey  are  lymph- 
channels.  In  this  case,  as  noted  on  p.  2-17,  there  are  some  \-eiy  l;ii-ge  cells, 
strongly  suggesting  a  sarcomatous  transformation  of  the  myoma. 


Fig.  97. — Irregular  Cystic 
Spacks  IN'  A  Myoma.  (Nat 
size.) 

Gyn.  No.  3113.  Path.  No. 
487.  -At  a  are  numerous  small 
cystic  spaces,  .some  of  which  com- 
municate with  one  another.  In 
this  case  there  were  edema  and 
hyaline  degeneration.  Some  of 
the  spaces  in  the  myoma  had  an 
endothelial  liniiiR  and  were  ap- 
parently dilate<l  lymph-channels; 
others  api)eared  to  he  due  to  dis- 
integration of  the  hjaline  ti.ssvie. 


124 


M  YUM  ATA    OF    TIIK    ITERl'S. 


Gyn.  No.  2852,     Path.  No.  347. 

A  u  t  ('  r  i  11  ('  111  y  o  m  a  w  i  I  h  c  y  s  t  i  c  s  j)  a  c  e  s  containing 
a   m  a  t  c  r  i  a  1   r  c  s  c  in  h  1  i  n  ti  in  cite  d   butt  c  r   (Fig.  98). 

M.  S.  1)..  inairit'd.  aged  forty-three,  white.  Athnitted  June  IS;  tliseharged 
July  .SO.  1S<)4. 

Patli.  Xo.  0-17.  The  spcciincn  consists  of  an  ciilargrd  utciiis  with  its  a|)pen- 
dages  intact  (Fig.  98).  The  uterus  is  globular  in  form  and  measures  13  x  13  x  1-4 
em.     It    is   smooth,  glistening,   ])inkish  in  color,  and  eN'eiywhere  covered  with 


^" 


Fig.  9S. — .\    Uterine    Myoma    with    Cystic    Spaces   Containing    Material    Resemhiinc    Mki.tkd  Bitter. 

(u  nat.  size.) 
Gyn.  No.  2852.     Path.  No.  347.     The  globular  myoma  contains  two  irregular  spaces,  the  upper  one  having, 
been  cut  in  two.     They  are  filled  with  butter-like  material,  which  contains  many  fat-droplets  and  cholesterin  crys- 
tals.    We  have  only  had  two  such  cases  in  a  large  series  of  degenerated  niyomata.      (.\fter  Howard  \.  Kelly.) 

peritoneum.  Th(>  posterior  wall  of  the  uterus  is  occupied  by  an  a])])arently 
rounded  nodule  12  cm.  in  diameter.  This  is  whitish  in  aj)i)earance,  and  is  made 
up  of  smaller  nodules  composed  of  concentrically  striated  fibers.  The  anterior 
])ortion  of  the  tumor  contains  a  cavity,  2  cm.  broad  and  2.5  cm.  in  de))th.  The 
walls  of  this  are  smooth  and  of  a  j^ellowish  color.  In  the  posterior  })ortion  of  this 
tumor  is  a  second  cavity.  This  measures  4.5  x  5  x  6  cm.  and  presents  a  convo- 
luted appearance,  has  smooth  walls  and  is  lined  with  a  yellow,  semisolid,  butter. 
like  material.     Both  cavities  are  filled  with  a  liquid  which  closely  resembles 


HYALINE    AND    CYSTIC    DEGENERATION.  125 

melted  butter.  Scattered  throughout  this  material  are  grayish-red  fioeculi  or 
streaks  of  blood. 

Histologic  Examination. — The  large  nodule  situated  in  the  posterior  wall  is 
composed  of  a  hyaline  stroma  with  non-striped  muscle-fibers  scattered  freely 
throughout  it.  The  muscle  in  the  vicinity  of  the  cavities  shows  patches  of  hy- 
aline degeneration,  associated  with  slight  lymphoid  infiltration,  or  ends  abruptly 
in  a  hyaline  material.  The  inner  walls  of  these  cavities  are  composed  entirely  of 
this  hyaline  substance,  with  a  few  muscle-fibers  scattered  here  and  there.  A  few 
blood-vessels  are  still  visil)le  in  the  hyaline  material.  The  ragged  inner  surfaces 
of  the  cavities  are  also  composed  of  hyaline  material,  but  the  individual  fibers  are 
still  faintly  visible.  In  no  place  is  there  the  slightest  evidence  of  polymorphonu- 
clear infiltration.  The  fresh  fluid  from  the  cavities  contains  many  cholesterin 
crystals,  large  round  cells  filled  with  fat-globules,  also  many  muscle-fibers  con- 
taining fat-dro})lets.     It  also  contains  much  granular  debris. 

The  probable  steps  in  the  degeneration  of  the  myoma  have  been  as  follows: 
(1)  Hyaline  degeneration  of  the  muscle-fibers;  (2)  emulsification  or,  in  other 
words,  degeneration  with  liquefaction  of  the  hyaline  material. 

The  most  striking  point  is  the  fact  that  the  degeneration  has  occurred  with- 
out any  reaction  whatever. 


CHAPTER  VTTT. 

CALCIFICATION  OF  UTERINE  MYOMATA. 

It'  one  systciiKitically  sections  all  iiiyoniata,  he  will  ho  surprised  at  the  fre- 
qiu'iK'V  with  which  gritty  ])articlos  are  found  scattered  throughout  the  tumors. 
On  the  other  hand,  it  is  rare  to  find  a  myoma  that  has  been  completely  trans- 
t'ornied.  into  a  calcified  nodule.  Calcified  areas  may  be  found  in  subperitoneal, 
interstitial  and  submucous  myomata;  though  in  some  cases  limited  to  one 
nodule,  at  othci-  times  they  are  pr(\sent  in  sevei'al  myomata  in  the  same  uterus. 


\Ct- -y  i/tHrf-t^ 


Fic.  99. — .\  Df.gknkkatki)  and  Partly  Cai.cifikd  Myoma.  (Nat.  size.) 
Gyn.  No.  3014.  Path.  No.  44.3.  The  uteru.s  contains  several  myomata.  Occupying  the  greater  part  of  the 
field  is  a  degenerated  interstitial  myoma  which  has  a  covering  of  uterine  muscle  (a).  In  the  outlying  portions  of 
the  myoma  are  many  white  calcareous  areas,  some  of  which  are  indicated  by  h.  At  c  remnants  of  myomatous 
tissue  are  still  in  evidence.  The  entire  center  was  occupied  by  a  pultaceous  mass  (rf),  which  to  the  examining  finger 
felt  like  ca.seous  material. 


The  calcareous  areas  are  usually  first  recognized  when  the  myoma  is  cut — the 
knife  at  once  encountering  areas  that  will  not  yield  or  that  are  gritty.  The 
myomatous  tissue  in  such  cases  may  be  dark-red,  yellowish-red,  or  gray,  but 
it  is  u.sually  yellowish  in  color,  friable,  and  very  like  a  caseous  lymph-gland. 
Calcareous  jxirticles  ar(>  at  times  so  small  that  they  are  scarcely  re('ogiiizal)le,  but 

l_'G 


CALCIFIC'ATIOX    OF    UTERINE    MYOMATA. 


12:; 


can  be  readily  detected  by  rubbing  the  tissue  between  the  fingers.     Where  the 
salts  are  liberally  deposited,  it  may  be  necessary  to  saw  jiortions  of  the  myoma. 

In  Case  7819  (Fig.  171,  p.  268)  carcinoma  of  the  cervix  was  present,  and  an 
interstitial  and  slightly  submucous  myoma,  about  5  cm.  in  diameter,  had  under- 
gone necrosis.  The  entire  outer  surface  of  this  myoma  was  encas(^d  in  a  calcified 
mantle. 

Case  3014  (Fig.  99)  shows  a  very  good  example  of  partial  calcification  of  a 
myoma.  The  central  portion  has  to  a  great  extent  undergone  softening,  sug- 
gesting a  caseous  gland.  In  the  outlying  portion  the  myomatous  tissue  is  still 
in  part  preserved,  but  in  many  places  are  found  large  and  small  deposits  of  cal- 
careous material.  Surrounding  the 
tumor  is  a  mantle  of  uterine  muscle. 

Fig.  100  shows  a  good  example  of 
the  various  stages  in  the  process  of  de- 
generation. The  uterus  contains  three 
small  myomata — one  is  soft,  a  second 
friable,  the  third  calcified. 

Histologic  Examination.  —  In  the 
early  stages  the  calcareous  deposit  may 
be  overlooked  macroscopically,  espe- 
cially if  the  deposit  of  salts  be  very 
scant.  In  such  cases  the  nuclei  of  the 
muscle-fibers  have  disappeared  entirely, 
but  the  fibers  can  still  be  made  out. 
Scattered  throughout  the  tissue,  are 
splotches  of  dark-staining  material, 
sometimes  forming  one  deeply  staining 
mass  with  hematoxylin,  but  oft(ni  ar- 
ranged in  w^avy  rows  (Fig.  101).  On 
careful  study  this  deeply  stained  mate- 
rial is  found  to  !)('  finely  gi-anular  and  at  numerous  points  refract iv(\  oblong, 
or  irregular  crystals  are  sometimes  seen.  Occasionally  calcareous  plates  ai'e 
found  in  the  outer  coats  of  the  bl()od-V(\ssels,  as  noted  in  Fig.  102. 

When  the  calcification  is  far  advanced,  it  is  necessary  to  remove  all  the  salts 
before  the  section  can  be  cut;  we  then  have  an  essentially  necrotic  tissue, 
totally  devoid  of  nuclei,  but  still  retaining  its  fibrous  arrangement. 


Fig.      100.- 


Vauioi's 


-Myomata       Representing 
Stages  of  Degeneration. 
Gyn.  No.  8270.     In  the  cervix  is  a  small  myoma. 

In  the  po.sterinr  wall  of  the  uterus  is  a  soft  myoma; 

lying  in  Douglas'  pouch  is  a  friable,  cheesy  myoma, 

which  was  5  cm.  in  diameter;    between  the  two  is  a 

j)artly  calcified  myoma. 


How  Calcium  Salts  are  Deposited. 
It  is  a  well-establisluMl  fact  that  in  ])ath()logic  conditions  (-ilciuin  snits  nie 
never  de})Osited  in  living  tissue.     The  most    ])olenl   f:ictoi-s  in   llie  (•;ius;ition  ot 
cell-death  are  the  lack  of  blood-supjtl.x-  and  the  iiijuiy  ivsulling  from  the  action 
of  toxic  substances. 


128 


MYOMATA    OF    TIIH    UTERUS. 


The  iiitcrcstiiiii  ('XjK'i'iliiciit  of  Littcii*  was  one  of  the  first  iiiij)ortant  stejis  in 
deterniiniii,i;'  llic  conditions  under  which  deposits  of  calcium  saUs  in  the  tissues 
may  occur.     W'lien  llie  renal  artei'v  of  a  ral)bit  was  tied  for  a  few  hovu's  and 


?U 


^. 


\'\i...  101. — P.\RTiAi.  Calcification  of  a  Myoma.  (X  SO  tliain.) 
Gyn.  No.  11898.  Path.  No.  8284.  The  specimen  is  from  a  pedunculated  myoma  which  has  undergone  hyaline 
degeneration  and  coagulation  necrosis  to  a  marked  degree.  In  the  field  from  which  this  picture  was  taken  prac- 
tically no  trace  of  cells  remained,  the  tissue  presenting  a  fibrillated  arrangement  and  staining  a  dirty  pink  with 
hematoxylin  and  eosin.  The  dark  wavy  areas  indicate  where  salts  have  been  deposited  in  the  necrotic  tissue. 
At  numcrou.^  points  small  crystals  of  the  chalky  deposit  stand  out  clearly,  as  is  well  seen  at  a. 

the  ligature  was  then  removed  and  the  blood  again  allowed  to  circulate,  Litten 
found  that  at  the  end  of  twent y-f(nir  hours  after  such  removal  the  kidney  tubules 
showed  the  presence  of  highly  refractive  granules,  which  microchemically  were 

*  Litten,  Zeit.'^clir.  f.  kliii.  .Mod..  1879,  I,  l.'U. 


CALCIFICATION    OF    UTERINE    MYOMATA. 


129 


found  to  consist  of  calcium  salts.  He 
and  calcium  phosphate  and  concluded 
that  these  substances  unite  ^vith  the 
ground-substance  of  the  cell  to  form 
an  insoluble  calcium  albuminate.  By 
injecting  copper  sulphate  into  the 
circulation  of  rabbits  he  obtained 
similar  results.  Since  that  time  many 
observers  have  found  d{'i)osits  of  cal- 
cium salts  in  various  tissues  following 
the  injection  of  many  irritants,  or- 
ganic and  inorganic.  Although  much 
has  l)een  written  on  the  deposition  of 
calcium  salts  in  the  tissues,  com- 
paratively little  was  added  to  our 
knowledge  of  the  chemical  nature  of 
the  process  until  the  recent  work  of 
Klotz  appeared.  The  conclusions 
reached  by  this  observer  may  be 
briefly  summarized  as  follows:  Pre- 
ceding the  deposit  of  these  calcium 
salts  there  are  fatty  changes  in  the 
tissues  involved.  These  in  turn  are 
followed  by  the  appearance  of  soaps 
or  soapy  substances,  which  unite  with 
the  albumins  of  the  degenerating  cells 
to  form  soap  albumins.  These,  with 
the  calcium  derived  from  the  blood, 
form  insoluble  calcium  curds  or  double 
calcium  soaps.  These  latter,  by  the 
action  of  substances  in  the  body  fluids 
containing  carbonic  and  phos])horic 
acids,  are  then  decomposed  into  phos- 
phate and  carbonate  of  lime  and  re- 
main as  ins(  )lub]('  deposits  in  the  tissue. 
For  further  consideration  of  this 
subject  the  reader  is  i-cfen-ed  to  the 
paper  of  Klotz*  and  the  ('oiii|)ivh('n- 
sive  review  of  the  literature  gi\-eii  by 
Aschoff.t 


determined  the  presence  of  carbonic  acid 


Fic.  1(JL'. — Calcareous  Platks  in  'ihk  W  ai.i.  ur  an 
AuTKRY.  (X  llOdiaiu.) 
Gyn.  No.  4364.  Path.  No.  1170.  The  uterus  was 
the  seat  of  a  tliffuse  adeiminynina  (see  .\<lenoniyoma  of 
the  Uterus,  p.  97).  The  ve.ssel  has  been  tortuous,  as 
the  picture  shows  two  cross-sections  of  the  same  lumen. 
The  various  areas  of  calcHicalioii  are  iiidicateil  liy  <i. 
This  calcareous  deposit  stains  .iceply  with  l\emato\yliii 
and  has  a  (iiii-ly  (rranuhir  appearance.  The  vessel  is  em- 
betliled  in  mi.\  imumIdiis  tissue. 


The  findings  in  one  of  our  cases  seem  to  indicate  that  electric  treatments  may 


*  Klotz.  .lour.  K\|).  Mi'd..  li»(»."),  vii.  iV.V.i  (17.'). 

t  Ascliotf,  I.uharsch-Ostt'rta.ir,  Krgebni.sse.  I'.tdJ.  Wi«-<l):i<lcn  IHIH.  viii.  .")(>1    .")S0. 


130  MYOMATA    OF    THE    ITKIU'S. 

in  some  way  favor  the  tlcjjositioii  of  calciuin  salts.  In  (liis  case  the  myomatous 
tumor  \v('i<!;h('(l  over  40  poiiiuls.  The  ])atii'nt  had  been  midcr  electric  treat- 
ment for  a  loii.ti:  period,  the  (>leetrodes  having  been  ai)i)li(Hl  to  the  opposite  sides 
of  the  abdomen.  On  llic  outer  surfaces  of  tlic  tumor,  at  the  points  correspond- 
ing to  the  places  at  which  the  electrodes  had  been  applied,  were  irregular  cal- 
careous j)la(iues  varying  from  4  to  6  cm.  in  diameter  and  from  1  to  2  mm.  in 
thickness. 

Total  Calcification  of  Myomata. 

We  ha\'e  had  several  cases  in  which  the  myomata  formed  solid  calcareous 
tumors. 

In  ("ase  ()47")  the  uterus  contained  several  myomata  and  there  was  an  adeno- 
carcinoma of  the  left  ovary.  Attached  to  the  right  uterine  horn  was  a  com- 
pletely calcified  myoma.  1  x  2  cm. 

In  Case  78.su  one  myoma  luid  been  pai'tly  transformed  into  a  caseous  material, 
and  projecting  from  the  anterior  uterine  walb  a  little  beneath  the  bladder,  was  a 
solid  calcified  myoma,  6  cm.  in  diameter. 

In  Case  8732,  in  which  the  uterus  contained  a  large  sarcoma  apparently  spring- 
ing from  a  myoma,  an  almost  totally  calcified  myoma  jii'ojected  from  the  surface 
of  the  uterus. 

In  Ca.se  4801^  a  pedunculated  myoma,  8  x  10  x  IG  cm.,  had  to  a  great  extent 
undergone  calcification. 

The  most  interesting  calcified  myoma  is  described  in  Path.  No.  5816  (Fig.  103). 
The  specimen  was  sent  us  by  Dr.  George  E.  Holtzapple,  of  York,  Pa.  It  was  as 
hard  as  stone,  markedly  lobulated,  and  measured  9  xll  x  15  cm.  It  had  been 
obtained  at  autopsy.  At  a  is  a  depression  which  coi'resjionds  to  the  site  of 
pedicle. 

Uterine  Stones. 

Our  attention  was  first  directed  to  this  sul)ject  by  a  study  of  Path.  No.  161.  In 
this  case,  during  I'emoval  of  carcinomatous  tissue  from  the  uterine  cavity,  a  cal- 
culus was  brought  away.  This  concretion  was  about  1.5  cm.  in  diameter  and  re- 
sernl)le(l  t  he  lialf  of  a  hollow  sj)here.  Its  outer  surface  was  rough  and  irregular  and 
at  several  j)oints  presented  a  mulberry-like  a])pearance.  The  iimer  and  concave 
surface  was  covered  with  friable  ti.ssue.  A  chij)  of  the  concretion  was  (examined 
by  Profes.sor  Welch,  who  failed  to  find  any  trace  of  bone-corj)iiscles.  Chemically, 
Professor  Abel  showed  that  it  was  compo.sed  of  CaX'03  and  Ca3(P04)2. 

It  is  difficult  to  explain  the  origin  of  the  calcareous  concretion.  The  most 
plausible  theory  is  that  it  is  the  remains  of  a  ])ait ially  calcified  myoma.  The  case 
is  reported  in  full  and  illustrated  in  "Cancer  of  the  Uteru.s, "  p.  412. 

Thorn.*  who  has  made  a  statistical  study  of  uterine  calculi  from  the  time  of 

*  Thorn,  .1.,  "Ziir  Kasuistik  dcr  I'terussteine,"  Zeit.  f.  (!cl).  u.  Cyii..  1S!)4,  Ud.  xxviii,  S.  7;"). 


CALCIFICATION    OF    UTERINE    MYOMATA.  131 

Hippocrates  down,  reports  a  similar  case.     If  an  interstitial  calcified  myoma 


Fig.  103 — A  Comim.ktki.y  Cai.cikiki)  Si;bi'kiiitom;ai,  Myoma      (|i  iiiit.  size.) 
Path.  No.  5816.     This  .specimen  was  removed  at  autop.sy  by  Dr.  (ieorRe  K.   Holtzapple,  of  York,  Pa.,  and 
sent  to  us  on  May  18,  1902.     a  represents  the  jioint  at  wliicli  the    pediele  was  altaeiied.      The  pedicle  did  not  be- 
come calcified,  but  gradually  alrnphiiil.  leaving  the  eavii\  ,      Tlw  tiiiMur  presiMiled  a  niullM-rry-like  surfaee.      It  was 
perfectly  .solid  and,  when  dropin'il  'uj  ilic  door,  fell  wiili  ilic  ilnid  of  a  ~,\,H\r 

becomes  siil^nuicous,  it  will  iiMlur;illy  in  time   he  extruded   tliiduii;!!   the  xa^ina 
as  a  so-called  uterine  stone. 


132  MYOMATA    OF    THE    UTERUS. 

Tabulation  of  the  Calcified  Myomata  Examined. 
The  accoiiii)anying  table  gives  a  fair  idea  of  the  mure  important   partly  or 
completely  calcified  myomata  that  have  come  under  our  observation. 

OvN.  No.  Path.  No.  Uteris.  Calcified  Myomata. 

2740 276 Multinodular.  One  nodule  calcified. 

:i()14 \i:\ Multinodular.  Interstitial  nodule,  5  cm.  in  diam.; 

outer  layers  calcareous,  center 
caseous  (Fig.  99,  p.  126). 

3130 499 Multinodular.  Tumor,  2.5  x  18  x  14  cm.     Calcareous 

areas. 

3340 607 .Multinodular.  Rough,  nudberry-shaped  myoma,  13 

cm.  in  diam.  Area  of  calcifica- 
tion 4.0  X  3  cm.  on  surface.  Cen- 
ter soft,  grayi.sh  yellow. 

3778 872 Montinodidar.  Several    nodules    containing    calca- 

reous deposits. 

3844 910   Multinodular.  Several    nodules     containing     calca- 

reous deposits. 

3950 970  Subperitoneal      peduncu-      Dense  omental  adhesions.     Calcified. 

lated  myoma. 

3985 986   Multinodular.  Nodule   in    front    of   cervix,   yellow, 

surrounded  hy  calcareous  de- 
posits. 

4160 1084   Two  subperitoneal  nodides.     Myoma,   7  x  .")  x  4.")  cm.:     pinkish 

yellow  or  bluish ;  small  calcareous 
deposits  beneath  peritoneum. 

4341 IIO.)   Sul)pentoneal  myoma.  Myoma,  6  x  4.5  cm.,  yellowish  with 

dark  center;  calcareous  deposits 
especially  near  capsule. 

4364 1170   Diffuse  adenomyoma.  Calcified    plates    in    vessel-walls    of 

uterus  (Fig.  102). 

4801  i 1392   .Mvdtinoilular.  Pedunculated  myoma,  S  x  10  x  16  cm.; 

greater  part  calcareous. 

4975    1.300    Multiiinihdar.  Some  small  interstitial  nodules,  cal- 

cified. 

5.303    17.>5    Abdominal     niyomoctumy     Yellow   patches;    some   contain   cal- 

(single).  cified  material. 

6479    2700    .Mvdtinodvdar.  Calcified  myoma.  1x2  cm.,  at  right 

CDI-IIU. 

6N33    3075^ Sul)mucous  myoma.  Mucli  c:dcareous  deposit. 

7775   4043    .Multinodular.  Two  of  nodules  calcified. 

7795   4055   .Multinodvdar.  Large  subperitoneal  myoma,  partly 

calcified.  i)artly  soft  and  degener- 
ated. 

7889 4136   Multinodular.  Calcified    myoma.    6    cm.  in  diam., 

under  bladder;  interfered  with 
bisection. 

8270   44.33   -Multinodular.  Large   calcified    myoma;     near   it   a 

chee.sy  myoma,  5  cm.  in  diam. 
(Fig.  100). 

8732   4931    Multinodular   with    sarco-     Subperitoneal  calcified  myoma  (Fig. 

matous    degeneration.  143,  p.  217). 


CALCIFICATION    OF    UTERIXE    :MY()MATA.  133 

Gyn.  No.  Path.  No.  Uterus.  Calcified  Myo.mata. 

11792   811G   Uterus   normal   in   size.  Subperitoneal  myoma,  15  x   12  x   8 

cm.;  hyaline  degeneration;  areas 
of  complete  necrosis;  points  of 
calcification. 

11898   8284   Subperitoneal  myoma.  Ad-  Microscopic     dark-purple     areas     of 

herent  omentum.  calcification  (Fig.  101,  p.  128). 

12779   9(542   Multinodular.  Myomata   show   hyaline    and   cystic 

changes  and  calcareous  deposits. 

San.  2189 1001.")   Multinodular.  Subperitoneal  myoma,  1.5  cm.;  small 

areas  of  calcification. 

Dr.  Holtzapple  .  .  5816  Large  subperitoneal  myoma  com- 
pletely calcified  (Fig.  103). 

W.,C.  H.  T 6421    Large,  globular.  Interstitial    myoma    with    sarcoma- 

tous degeneration.  Areas  of  cal- 
cification (Fig.  131,  p.  193). 

Clinically,  these  calcified  niyoniata  are  of  little  import.  A  degenerated  my- 
oma, when  soft,  may  become  infected,  but  when  once  calcified,  usually  gives  little 
or  no  trouble.     It  cannot  be  well  diagnosed  as  calcified  prior  to  operation. 

To  the  surgeon  the  condition  may  offer  certain  obstacles,  on  account  of  the 
difficulty  in  getting  at  the  uterine  vessels,  or  ^^■hen,  as  a  result  of  adhesions,  bi- 
section is  deemed  necessary,  since  it  may  be  impossible  to  cut  through  the  cal- 
cified nodule.  This  difficulty  may  be  readily  overcome  by  merely  shelling  the 
tumor  out  and  then  completing  the  bisection.  We  have  seen  operators  in  re- 
moving myomatous  uteri  by  the  vagina  have  untold  difficulty  with  a  large  cal- 
cified myoma.  In  fact,  we  have  seen  them  resorting  to  the  saw  and  removing 
the  calcified  nodule  piecemeal. 


("I[apti:p.  IX. 

SUPPURATING  UTERINE  MYOMATA. 

In  this  (*haj)t('r  \vc  iiu-liulc  only  those  cases  hi  which  the  pus  formation  oc- 
curreil  in  niyoniata  situated  on  the  outer  surface  of  the  uterus,  or  located  in  the 
musculatui'e.  Suppurating  inyoniata  are  (li\isil)le  into  \hvvv  definite  classes: 
(1)  Suhj)eritoneal:  (2)  interstitial;  (3)  submucous.  However,  inasmuch,  as  the 
subnuicous  variety  has  certain  characteristics  totally  different  from  those  of  the 
other  two  classes,  they  will  he  discussed  hi  another  j)lace. 

SUPPURATING  SUBPERITONEAL  MYOMATA. 

We  have  had  five  cases  of  this  character,  and  two  other  interesting  specimens 
have  been  referred  to  us.  In  Case  12216  (Fig.  104),  on  section,  a  multinodular 
uterus  was  found  reaching  to  the  umbilicus.  The  most  prominent  myoma  was 
densely  adherent  to  the  anterior  abdominal  wall,  over  an  area  4x4  cm.,  and 
there  were  also  omental  adhesions.  As  soon  as  the  myoma  was  separated  from 
the  abdominal  wall,  jnis  trickled  down  its  surface  from  a  cavity  situated  ilirectly 
beneath  the  point  at  which  the  abdominal  adhesions  had  existed.  This  cavity 
measured  7x5  cm.  and  was  filled  with  pus. 

In  Case  3216  a  myoma,  23  cm.  in  diameter,  was  attached  to  the  left  side  of  the 
uterus  (Figs.  105  and  106).  On  account  of  the  septic  temperature  pus  was  sus- 
pectetl.  On  tapping,  4700  c.c.  of  creamy  pus  were  evacuated.  The  tumor  was 
released  from  the  omental  adhesions  and  the  uterus  and  its  a]ij)endages  were 
removed. 

Case  15281  furnished  one  of  the  most  interesting  of  our  series.  The  ])atient, 
some  months  prior  to  her  labor,  noticed  a  small  abdominal  tumor.  Her  labor 
was  uneventful,  but  a  few  weeks  later  she  entered  the  hos])ital  very  ill.  At  opera- 
tion a  su]i])urating,  pedunculated,  subperitoneal  myoma  was  found.  This  had 
ru])tured  and  an  absces^s  sac  had  developed  between  the  myoma,  the  omentum, 
loops  of  small  bowel,  and  the  right  lateral  abdominal  wall  (Figs.  107  and  108). 

In  February,  1895,  Dr.  David  A\'.  Houston,  of  Troy,  N.  Y.,  sent  us  a  portion 
(jf  a  subperitoneal  myoma  which  a  woman,  fifty-five  years  of  age,  had  carried 
for  thirty  years.  The  central  portion  of  the  tumor  had  been  converted  into  an 
abscess  containing  10^  quarts  of  pus. 

Suppurating  s  u  b  p  e  r  i  t  o  n  e  a  1  m  y  o  m  a  t  a  co  m  m  u  n  i  c  a  t  - 
i  n  g  w  i  t  h   the  bo  w  e  1  . 

In  three  of  the  seven  cases  of  suppurating  subperitoneal  myoma  the  abscess 
had  opened  into  the  bowel.     In  Case  7549  the  whole  abdonu^n  was  filled  with  a 


SUPPURATING    ITHHIXE    MYOMATA.  135 

large  myomatous  uterus.  In  the  upper  part  was  a  large  irregular  abscess  com- 
municating with  the  colon  (Fig.  109). 

In  Case  9078  a  partially  ])arasitic  myoma  contained  an  abscess  cavity.  This 
conmumicatecl  freely  with  the  cecum,  fecal  matter  passing  from  the  bowel  to  the 
cavity  in  the  mj^oma.     This  case  is  reported  in  detail  on  p.  45  (Fig.  32). 

In  Hundley's  case  the  parasitic  myoma  had  received  its  nourishment  from 
the  small  bowel.  The  interior  had  been  converted  into  an  abscess  sac  and  fecal 
matter  passed  directly  from  the  bowel  into  the  myoma  and  back  again  to  the 
bowel.  This  case  is  likewise  reported  in  detail  in  the  chapter  on  Parasitic 
Myomata  (p.  47,  Fig.  33). 

Cases  of  Suppurating  Subperitoneal  Uterine  Myomata. 
Gyn.  No.  122 16.     Path.  No.  8825. 

Cervical,  i  n  t  e  r  s  t  i  t  i  a  1  ,  a  n  d  s  u  Id  p  e  r  i  t  o  11  e  a  1  m  y  o  m  a  t  a  ; 
necrosis  of  a  large  s  u  I3  p  e  r  i  t  o  n  e  a  1  m  y  o  m  a  ,  ^^'  i  t  h  ab- 
scess formation  (Fig.  104);  dense  adhesions  to  the 
abdominal  wall  and  to  the  o  m  e  n  t  u  m  . 

M.  H.,  colored,  aged  twenty,  married.  Admitted  July  5;  died  July  15, 
1905.  She  has  never  been  pregnant.  For  about  ten  months  she  has  had  definite 
pain  of  a  sticking  character  in  the  right  side  of  the  abdomen.  Early  in  the  onset 
of  the  present  trouble  she  felt  a  small  mass  in  the  right  side,  which  has  gradually 
increased  in  size.  The  pain  has  been  associated  at  times  with  fever,  more  marked 
at  the  menstrual  period.  Four  months  ago  the  patient  had  considerable  diffi- 
culty in  getting  the  bowels  to  move;  the  abdomen  was  swollen  for  three  or  four 
weeks,  and  there  was  some  vomiting.  For  the  last  three  weeks  the  patient  has 
had  shortness  of  breath,  dizziness,  and  night-sweats. 

Operation,  July  <S,  1905.  Hysterectomy  was  done  in  the  usual  manner. 
There  was,  however,  consideralile  difficulty  in  liberating  the  most  prominent 
myoma  from  the  anterior  abdominal  wall.  After  liberation  of  the  adhesions, 
pus  commenced  to  trickle  down  from  the  surface  of  the  myoma  (Fig.  104). 
Care  was  taken  to  cover  in  the  raw  peritoneal  area  as  far  as  possible  by  bringing 
the  peritoneal  surfaces  together  with  catgut.  On  the  sixth  day  after  operation 
the  patient  de\'e]o](e(l  partial  intestinal  obstruction.  The  patient  did  fairly 
well  for  two  days,  when  she  had  a  sudden  attack  of  abdominal  i)ain,  colick\-  in 
character.  The  bowels  had  moved,  and  iier  temj)erature  was  normal.  The 
bowels  wer{>  moved  again  two  or  three  times,  hut  the  distention  increased. 
The  temperature  remained  ahout  99°  l'\ 

July  15th.  lv\i)loratory  laparotomy.  When  the  ])atieiit  was  j)laced  under 
ether,  vomiting  commenced.  This  was  decidedly  fecal  in  ('liai'acter,  although 
there  had  been  no  vomiting  in  the  ward.  The  ahdominal  ca\ity  contained  a 
moderate  amount  of  clear  .serum  and  the  intestines  were  e\-ery\vhere  distended. 
In  the  right  (|uadrant  they  were  fastened  to  the  anterior  abdominal  wall  at  the 


136 


MYOMATA    OF    THE    UTERUS. 


point  at  which  the  sui)|)uratiiiti  iiiyoina  had  lu'cn  adhcroiit.     The  patient  died 
ahnost  itnnicdiatcly.     At  autopsy  it  was  found  that  the  intestine  at  t\w  site  of 

the  adhesions  was  bent   upon  itself   at 
a  sharp  angle.     The  highest  postopera- 
tive   temperature    was    100.5°   F.      In 
&dVv^K"^^^Hl  this  case   it  would  have  been  wiser  to 


Fig.  104. — .\  Suppurating  Subpkritonkai.  Myoma.     («  nat.  size.) 
Gyn.  No.  12216.     Path.  No.  S.S2.5.     The  uterus  is  seen  from  the  side.     The  myoma  to  the  left  encroached  on 
the  bladder.     That  on  the  right  wa.s  densely  adherent.     Occupying  the  upper  part  of  the  uterus  is  a  large  globular 
myoma.     Over  the  area  indicated  by  a  it  was  densely  adherent  to  the  anterior  abdominal  wall.     \t  b  pus  is  welling 
from  the  interior  of  the  myoma.     The  omentum  is  adherent  over  a  wide  area 


SUPPURATING    UTERIXI-:    MYoMATA.  137 

have  done  an  explonitoiy  opcraticjn  caiiicr,  when  the  patient  was  in  good  con- 
dition; the  chance  of  success  would  then  have  been  much  greater. 

Path.  No,  8825.  The  specimen  consists  of  a  myomatous  uterus  approxi- 
mately 12x12  cm.  Projecting  from  the  cervix,  and  extending  down  into  the 
broad  ligament,  is  a  myoma  7  cm.  in  diameter.  There  is  also  one  of  smaller  size, 
springing  from  one  horn,  and  scattered  throughout  the  walls  of  the  uterus  arc 
several  smaller  nodules.  The  chief  interest  is  centered  in  the  sul)peritoneal 
nodule,  10  x8x8  cm.  Attached  to  its  surface  is  a  large  tag  of  omentum.  Pus 
flows  from  a  rent  in  the  myoma.  On  the  surface,  in  the  vicinity  of  the  omental 
adhesions,  is  a  raw  area  4x4  cm.  At  this  point  the  growth  was  adherent  to  the 
abdominal  wall  and  had  literally  to  be  cut  away.  This  subperitoneal  myoma 
is  in  part  covered  with  numerous  adhesions.  On  section,  it  is  found  to  have 
broken  down  over  a  considerable  area.  The  myoma  has  evidently  first  under- 
gone necrosis.     AVe  have  an  irregular  cavity,  7x5  cm.,  filled  with  pus. 

Histologic  Examination. — Sections  from  the  subperitoneal  myoma  which 
contained  a  quantity  of  pus  show  that  a  large  portion  has  undergone  h3^alinc 
degeneration  and  coagulation  necrosis.  Such  areas  are  almost  entirely  devoid 
of  cell-elements.  The  inner  surface  of  the  abscess  wall  is  bathed  in  polymor- 
phonuclear leukocytes  and  necrotic  material.  The  underlying  myomatous 
tissue,  where  hyaline  degeneration  has  taken  place,  shows  a  good  deal  of  small- 
round-celled  infiltration  and  the  formation  of  many  new  connective-tissue  cells 
around  the  blood-vessels.  There  has,  in  this  case,  undoubtedly  been  a  primary 
necrosis  followed  by  infection. 

Gyn.  No.  3216.     Path.  No.  534. 

A  s  u  p  p  u  r  a  t  i  n  g  i  n  t  r  a  1  i  g  a  m  e  n  t  a  r  y  m  y  o  m  a  (  Figs.  105, 
106)  ;    slight    p  e  r  i  -  o  (J  p  h  o  r  i  t  i  s    on    1)  o  t  h    sides. 

A.  S.,white,  aged  forty-four,  married.  Admitted  December  1, 1894;dischai'ged 
January  1,  1895.  The  patient  has  had  eight  children  and  one  miscarriage.  Six 
years  ago  she  noticed  an  enlargement  of  the  left  lower  abdomen  and  there  was 
some  "sticking"  pain.  The  tumor  has  gradualh'  increased  in  size,  both  sides 
being  now  involved,  and  she  has  a  constant  dragging  ])ain,  occasionally  sharp  and 
bearing  down  in  ehanicter.  She  is  weak  and  has  l)een  having  a  se])tic  teni])era- 
ture. 

Operation,  Deceinbei'  ;!,  IS91.  llysteroinyoinectoniy.  A  densely  adherent 
suppurating  intraligamentary  niyoina  was  found  and  tapped,  1700  v.v.  of  creamy 
pus  being  removed.  There  were  dense  omental  adhesions.  The  tempei'alui'e, 
which  was  100.6°  F.,  rose  a  lit  tie,  and  then  tell  loiiornial.  It  I'ose  again  to  103°  !•'. 
on  tlu!  nineteenlh  day.  williout  ;i|)i)an'iit   iv;ison,  and  al'ler  lliat  became  iioinial. 

Path.  No.  534.  The  siK'cimen  consists  of  llic  uterus,  with  a  large  tumoi' 
springing  from  its  left  side,  and  both  tubes  ami  o\aries.  The  tunioi',  which  is 
globular,  is  23  cm.  in  diameter.  It  springs  from  the  left  side  of  the  ulems.  ap- 
pai'ently  arising  fi'oin  the  left  utei-ine  eoi-iui.  just  beneath  the  tube  (Figs.  105  and 


138 


MVO.MATA    OF    THH    ITKIUS. 


106).  It  then  jiasscs  out  Ix'twccu  the  layers  of  the  hroad  ligament,  being  covered 
with  ])eritoneuin.  It  is  whitish  yellow  or  pinkisli  in  color,  is  covered  with 
numerous  adhesions,  and  is  adherent  to  the  omentum  over  an  area  8x8  cm. 
On  pressure  it  is  somewhat  elastic.  On  section,  the  tumor  is  seen  in  places  to  be 
covered  with  a  layer  of  nmscle,  4  nun.  in  thickness.  This  covering  gradually 
disappears  as  the  tumor  passes  toward  the  broad  ligament.  The  tissue  of  the 
tumor  is  grayish-pink  in  color  and  is  ver}^  edematous.  It  is  divided  up  into 
large  and  small,  irregular  oval  masses.  These  contain  numerous  Ijmiph-spaces, 
the  largest  of  which  is ')  inn  1.  in  diameter.  In  the  center  of  the  tumor  is  a  cavity, 
15  cm.  in  diameter,  and  having  somewhat  irregular  and  ragged  walls.     The  inner 

surface  is  covered  with  a  yel- 
lowish membrane,  1.5  mm.  in 
thickness.  Attached  to  this 
membrane    are    many    whitish- 


■^If^^i- 


J* 


Fig.  105. — .\n  Intrai.igamentary  Suppurating  Myoma.     (,|  nat.  size.) 
CJyn.  No.  3216.     Path.  No.  534.     Springing  from  the  left  of  the  uterus  is  a  large  globular  myomatous  tumor, 
that  shows  dense  adhesions  on  its  upper  and  outer  surfaces.     The  uterus  and  right  appendages  are  normal.     The 
left  tube  is  marketlly  elongated,  as  the  result  of  stretching  by  the  tumor,  and  the  left  utero-ovarian  ligament  is 
much  lengthened.     For  the  interior  of  the  myoma  see  Fig.  106. 


yellow  flakes,  resembling  those  found  in  a  i)unilent  jxTitonitis.  The  cavit}^ 
contains  3000  c.c.  of  dirty,  bluish-green  ))us,  which  microscopically  is  found  to 
be  composed  of  polynior]:)honuclear  leukocytes  and  degenerat(^d  cells  containing 
fat-droplets  and  debris.  Numerous  diplococci  are  also  seen.  Coursing  over  the 
outer  surface  of  the  tumor  is  the  left  Fallopian  tul)e.  which  takes  a  curve 
directly  outward,  backward,  and  then  inward.  The  uterus  and  th(>  appendages 
on  the  opposite  side  are  of  little  interest. 

Histologic  Examination. — The  large  tumor  everywhere  shows  moderate  hya- 
line degeneration.  In  the  vicinity  of  the  cavity  the  muscle  is  very  rich  in  blood- 
vessels, many  of  which  have  undergone  complete  hyaline  degeneration.  In 
some  places,  however,  the  endothelium  still  persists.     The  muscle-fibers  in  this 


SUPPURATIXG  utt<:rixk  MYo.MATA. 


139 


region  stain  niucli  more  decpl}'  than  in  the  outer  portion  of  tlie  tumor.  In  many 
places  the  muscle  shows  aggregat icons  of  newly  formed  connective-tissue  cells. 
Still  farther  inward  the  entire  nmscular  substance  has  undergone  hyaline  degen- 
eration, and  scattered  throughout  this  hyaline  material  are  a  moderate  number  of 
polymorphonuclear  leukocytes.  Just  beneath  the  inner  surface  the  tissue  has 
undergone  coagulation  necrosis.  The  inner  surface  of  the  cavit)^  at  such  points  is 
covered  with  polymorphonuclear  leukocytes.  In  other  places  the  tissue  presents 
a  typical  granulation  surface.  .Many  polymorphonuclear  leukocytes,  both  on  the 
surface  and  in  the  depth,  are  swollen  and  appear  to  contain  fat-droplets.  This 
is  a  most  striking  example  of  a  suppurating  intraligamentary  myoma. 


Fig.  lot). — A  Suppuratinc;  Intrai.icamkntauv  Myoma.     {!,  nat.  size.) 
Gyn.  No.  3216      Path.  No.  534.     This  represents  the  posterior  half  of  the  tumor  .seen  in  Fig.  105.     The  uterus 
and  right  appendages  are  normal,     a  represents  the  outer  covering  of  normal  uterine  muscle;  6,  myomatous  tissue. 
Over  half  the  tumor  has  l)e(>n  converted  into  an  abscess  sac. 


Gyn.  No.  15281.     Path.  No.  13121. 

A  s  u  ))  p  u  r  a  t  i  n  g  s  u  b  p  e  r  i  t  o  n  e  a  1  p  e  d  u  n  c  u  1  a  t  e  d  m  y  o  - 
m  a  ,  w  h  i  c  h  r  u  p  t  u  r  e  d  a  11  d  f  o  r  111  e  d  a  11  a  b  .^  cess  b  c  t  w  e  e  11 
the  o  m  (■  n  t  u  m  ,  s  m  all  bo  w  el,  a  n  d  right  1  a  t  e  r  a  1  ab- 
dominal   wall    (Fig.^.    107.   108)  . 

A.  W., married, aged  I  weiity-oiic,  colored.  .Vdmil  ted  XoNcmbci-  io  ;  dischai'ged 
December  17,  lOOS.  She  complain.'^  of  a  "knot  "  in  1  he  I'iglil  side  of  t  he  abdomen. 
The  patient  has  been  mari'ied  ten  niontlis  ;in(l  lias  one  cliild,  a  month  old.  In 
March,  1908,  sh(>  experienced  sliai-p  bearing-down  pain  in  the  right  .side  of  the 
pelvis,  and  at  that   time  noticed  a  luni|)  which   was  apparently  about  (i  cm.  in 


140 


MVO.MATA    OF    THK    UTERUS. 


diameter  occup^inii  the  riiilit  iliac  fossa.  The  pain  was  dull,  achiiiii  in  character 
and  constant.  Since  then  the  pain  has  increased  more  or  less  and  has  been 
aggravated  on  many  occasions  by  exertion.  There  was  no  increase  in  the  size  of 
the  tumor  until  the  termination  of  pregnancy.  She  has  complained  of  no  back- 
ache, but  of  much  headache.  Her  labor,  one  month  ago,  was  perfectly  normal. 
She  states  that  during  the  early  pregnancy  there  was  occasionally  fever  and 
during  the  last  few  days  she  has  had  considerable  nausea  and  vomiting. 

On  admi.ssion  she  appears  to  be  quite  sick.     The  tongue  is  brownish  in  color 
and  coated.     The  ])ulse    is  of  fail' 
volume.  lo()  to  the  minute. 


Jh.  omertt-jm 


Acl4eS-o 
par  etal   pari 


Fit;.  107. — A  Suppurating  Subperitoxk.al  Myoma. 
Oyn.  No.  1.52S1.      I'atli.  No.  13121.     The  uterus  is  normal  in  size,     .\ttacheil  in  the  fundus  is  a  peihiuoulated 
myoma  which  had  .sui)i)urated  and  ruiitured.     On  the  outer  side  it  wa-s  adherent  to  the  atxlominal  wall,  on  the 
inner  side,  to  the  omentum  and  small  bowel.     For  the  interior  of  the  myoma  see  Fi?.  108. 


Abdominal  i^xamination  :  ( )\'er  the  lower  two-tiiirds,  on  the  right  side  of  the 
abdomen,  is  a  distinct  owil  jjiomiiicnce.  and  on  palpation  this  area  is  firm, 
slightly  tender,  and  has  a  brawny  feel.  No  fluctuation  can  be  made  out,  but  there 
is  a  slight  yielding  of  the  tumor.  This  mass  is  firmly  fixed.  On  vaginal  exam- 
ination nothing  can  be  detected. 

Her  hemoglobin  was  80  percent.:  leukoc3^tes,  24,000.  An  incision  was  made 
through  the  right  rectus  and  the  mass  immediately  (>xpos(>d.      Over  its  surface 


SUPPURATING    UTEKIXK    MYOMATA. 


141 


the  oinontuni  was  firinl}'  tulhen'iit.     On  its  inner  side  were  adherent  intestinal 
loops.     On  its  outer  side  it  was  firmly  fixed  to  the  lateral  abdominal  wall.     The 
mass  was  carefully  walled  off  on  all  sides  and  Ww  omentum  then  o;radually  with- 
drawn.    There  was   an  innnediatc  escape 
of  very  fetid   pus.     This  came  from   the 
inner  side  of  the  mass  and  also  from  the 


Suppurating'  subperitoneal, 
myoma 


\     m 

IH 

I 

■ 

N» 

y 

P 

i 

w 

:        r.  tu]t>€ 
r.  ovary 

^aN^^' 

.:?■' 

Omeni 

uni 

adherent    to  tumor 

Fk;.    108. A    SUI'ITIIATINO    SlUU'ERITONKAr.    M\(IM\. 

CJyii.  No.  152.S1.  I'alli.No.  i;n21.  The  uteni.s  was  normal  in  size,  !)Ut  on  paipiilinn  a  few  .small  m.\i>mala 
could  he  felt.  Attached  to  the  fundus  by  a  broad  pediole  was  a  suppuratiiiR  myoma.  DurinR  pregnancy  it  had 
been  carried  upward  and  lay  above  anil  to  the  right  of  the  umliilicus.  Uere  it  had  become  fixed.  Us  center  was 
filled  with  pu.s  and  necrotic  tissue.  \X  had  ruiJlured.  but  was  walled  off  on  the  median  and  anterior  surfaces  by 
the  omentum  and  small  bowel;  on  the  outer  side,  by  the  lateral  abdominal  walls.     The  api)cndaKes  were  normal 

vicinity  of  the  ahdominal  wail.  (  )ii  l)ciiiu-  .irfadually  lod.^ciicd  up  it  was  found  to 
be  a  myoma  which  was  attached  to  the  uterus  by  a  rathci'  broad  ])C(hch'  (Fifj. 
107).     The  tumor  was  freed  abo\-e  ;ui(l  l;itei-;illv  and  then  the  uterus  was  (h'awn 


142  MYO.MATA    OF    THK    UTKIU'S. 

out.  The  Uterus,  tuhcs.  and  ovaries  were  ])ert'eetly  normal.  The  pedicle  of 
the  luyonia  was  cut  across,  and  the  I'aw  aiva  closed.  A  small  drain  was  laid  in 
the  pelvis  and  also  in  the  pocket  from  which  tlie  tumor  had  been  removed. 
The  tissues  in  all  directions  were  hanl  and  edematous,  the  omentum  was 
marke(llv  thickened,  and  the  ahdominal  wall  roughened.  The  intestines  were 
covered  with  a  pN'ogenic  meml)rane. 

Xovemher  2()th:  The  j)atient  is  in  excellent  condition.  Her  temperature 
and  pul.se  are  normal.  The  abdominal  wound  has  to  a  great  extent  closed,  but 
there  is  considerable  discharge,  which  seems  to  be  fecal  in  character.  We  are 
not  at  all  surj^ri.sed  at  this,  on  account  of  the  implication  of  the  intestinal  loops 
in  the  abscess  wall.  The  wound  closed  completely,  and  the  patient  was  discharged 
well  on  December  17,  H)OS. 

Path.  Xo.  1."!I2I.  The  specimen  consists  of  a  myoma  a))proximately  8  cm. 
in  length  and  7  cm.  in  diameter.  This,  on  its  outer  surface,  presents  a  rather 
worm-eaten  appearance,  especially  where  it  was  adherent  to  the  abdominal 
wall  (Fig.  lOS).  The  raw  area  indicating  the  site  of  the  pedicle  is  4  cm.  in  length 
and  2.0  cm.  broad.  The  entire  central  portion  of  the  tumor  is  irregular, 
yello^^sh- white  in  a])))(vi ranee,  and  has  trabecula'  extending  from  side  to  side 
over  a  consideralile  aica.  The  walls  vary  from  2  cm.  to  not  more  than  1  mm.  in 
thickness  and  in  some  places  have  given  way  entii'ely.  Occupying  the  central 
portion  are  grayish-yellow  necrotic  masses.  The  largest  of  these  measures  2.5  x 
o  cm.  Filling  in  all  the  interstices  of  the  center  is  grayish-yellow,  offensive  pus. 
This  had  trickled  out  between  the  tumor  and  the  lateral  abdominal  wall  and 
likewise  between  the  bowel  and  the  omentmn  on  the  inner  aspect. 

Histologic  Examinati(jn. — Sections  from  some  portions  of  the  growth  show 
the  typical  myomatous  picture.  At  other  points  there  is  marked  hyaline  trans- 
formation, with  li(iuefaction.  The  walls  of  the  abscess  are  composed  of  typical 
granulation  tissue,  which  is  very  va.scular  and  in  })laces  hemorrhagic.  Scattered 
throughout  the  walls  ar(>  many  polymorphonuclear  leukocytes  and  small  round 
cells.  The  growth  is  essentially  a  myoma  which  has  undergone  suppuration  in 
its  central   ))()rtion. 

Gyn.  No.  7549.     Path.  No.  3799. 

Small  subperitoneal  and  interstitial  uterine  my- 
o  m  a  t  a  :  large  si  o  u  g  h  i  11  g  s  u  b  p  e  r  i  t  o  n  e  a  1  m  y  o  m  a  c  o  m  - 
m  u  n  i  c  a  t  i  n  g    w  i  t  h    the    c  o  1  o  n    (Fig.  109). 

K.  H.,  aged  thirty-Hve,  white,  single.  Admitted  February  1;  discharged 
March  22,  1900.  Occupying  the  lower  and  median  portions  of  the  abdomen  is  a 
large  irregular  mass.  This  is  smooth,  hard,  freely  movable  from  side  to  side, 
and  continuous  with  a  large  jK'lvic  growth. 

Operation,  February  .'^  1900.  Hysteromyomectomy.  On  section  of  the  ab- 
domen the  transverse  colon  was  found  so  fii-nily  adherent  to  the  tumor  that  sepa- 
ration was  imj)o.ssible.  The  cervix  was  at  once  located,  cut  across,  and  the 
uterus  turned  out  so  that  the  adhesions  were  gotten  at  from  the  under  surface. 


SUPPURATIXG    UTERIXE    MYOMATA. 


143 


The  myoma  contained  an  abscess  cavity  whicli  coiiiiiiunicated  witli  the  colon. 
The  operation  is  described  in  detail  on  p.  613.  The  patient  had  a  fecal  fistula 
when  she  left  the  hosj)ital.  Tliis  is  hardly  to  l^e  wondered  at,  considering  the 
markedly  indurated  ojjening  noted  in  the  cecum  at  oj)eration. 

Path.  No.  3799.  The  greater  part  of  the  myoma  lies  above  the  utc^rus.  In 
its  upper  part  is  a  iai'gc  sloughing  cavity  which  ojjcns  on  the  surface  and  has 
connnunicated  directlv  with  the  bowel. 


\^^^^%:M 


Fk;.  109. — A  Si'i-i'i'RATixc  M-iOMA  Oi'km.ng  into  thk  Colon. 
Gyn.  No.  7.')49.     Path.  No.  .3799.     Occupying  more  than  half  of  the  abdomen  is  a  niyoniatovi.'s  tumor.     Rs 
upper  ijart  contains  an    irregular  al)sees.s    cavity  which  empties    into  tlie    colon.      For  a  full  description  of    the 
operative  difficulties  in  this  case  see  p.  613.     (.\fter  Howard  A.  Kelly,  i 

()ii  histologic  exainiiiation  ])oiliotis  of  the  iiiyoiiin  litiing  llie  al)scess  (•a\'ity 
ar(>  entirely  iiecrolic.  The  surface  is  eo\-ei'e(l  with  many  polyiiioiphoiiuelear 
leukocytes,  which  also  haxc  infill  caled  the  undeiiyiug  tissue  Idi'  a  ('onsideral)le 
distance.  Apart  from  this  no  lUK'lei  aic  anywhere  demonstrable.  Had  we  not 
first  cut  across  the  cervix  and  then  attacked  the  cecal  adhesions  from  behind, 
the  case  would  ha\'e  been  ino|)erable. 


144  MYOMATA    OF   THK    TTERUS. 

Path.  No.  605. 

A    s  u  p  ])  u  r  a  t  i  n  g    s  u  I3  p  (>  r  i  t  o  n  v  a  1    11  t  v  r  i  ii  c    m  y  o  111  a  . 

Patient  of  Dr.  Houston,  Troy,  N.  V.  The  tumor,  a  subperitoneal  myoma 
that  contained  10^  quarts  of  ]ius.  liad  been  obtained  from  a  woman  fifty-five 
years  of  age,  who  had  carried  it  foi'  thirty  years.  The  specimen  received  l)y  us 
for  examination  in  February.  J  SO"),  consisted  of  a  ])()rtion  of  the  wall  of  this 
abscess. 

Plistologic  Examination.  The  tissue  is  composed  of  non-strijx'd  nniscle- 
fibers  cut  longitudinally  and  transversely.  It  has  a  fairly  rich  blood-supply. 
Along  the  outer  margins  of  the  tumor  the  muscular  tissue  stains  poorly.  There 
is  a  mod(n"ate  nuclear  fi'agmentation  and  marked  ])olyniorphonuclear  infiltra- 
tion. The  inner  surface  is  entirely  necrotic  and  devoid  of  nuclei.  Scattered 
throughout  this  necrotic  material  are  masses  of  micro-organisms  Avhich,  when 
stained.  ])rove  to  be  cocci.     They  are  arranged  singly  oi"  in  short  chains. 


SUPPURATING   INTERSTITIAL   UTERINE   MYOMATA. 

In  (iyn.  \o.  8707  the  globular  uterus  was  LS  cm.  in  diameter.  The  gi'eat  in- 
crease in  size  of  the  abdomen  was  due  to  an  interstitial  myoma,  17  cm.  in  di- 
ameter, occupying  the  posterior  wall.  The  uterine  cavity  was  15  cm.  in  length, 
and  its  muco.sa  scarcely  1  nun.  in  thickness.  At  one  point  in  the  posterior  wall 
the  nmcosa  over  an  area  7  x  o  cm.  had  entirely  disappeared  and  the  portion  of 
the  myoma  projecting  through  was  brownish  in  color,  roughened,  and  disinte- 
grating (Fig.   111).     The  entire  myoma  was  rather  soft. 

In  Gyn.  No.  5093,  as  soon  as  the  cervix  was  cut  at  operation,  a  stream  of 
brownish,  tenacious  mucus  poured  out.  The  uterus  had  been  converted  into  a 
globular  tunioi-  22  cm.  in  diameter.  ()ccu{)ying  the  anterior  wall  was  a  large 
myoma  which  was  imdergoing  necrosis.  The  uterine  cavity  was  16  cm.  long 
and  at  the  fundus  reached  5  cm.  in  breadth.  At  two  points  over  the  large  myoma 
the  nmcosa  had  disap])eared  and  the  underlying  mA'omatous  tissue  was  dark 
l)luish  red  and  necrotic.  The  larger  area,  4  cm.  in  its  longest  diameter,  had 
sharply  defined  rounded  margins  (Fig.  112). 

In  Case  5617  the  patient  gave  definite  signs  of  sepsis.  The  uterus  was 
globular  and  averaged  22  cm.  in  diameter.  The  uterine  ca\'ity  was  greatly  en- 
larged. Occupying  the  anterior  wall  was  a  myoma,  17  cm.  in  diameter,  over 
which  the  nuico.sa  was  atrophic.  Near  the  center  of  the  cavity  the  tumor  was 
devoid  of  mucosa  over  an  area  10  cm.  in  diameter  and  here  it  had  been  trans- 
formed into  a  ragged,  sloughing  mass. 

In  San.  No.  1847  the  patient,  prior  to  operation,  had  had  chills  and  fever. 
The  uterus  mea.'^ured  10  x  9x  S  cm.  There  was  a  diffuse  myomatous  thickening 
of  the  vUei'iis.  a  submucous  myoma,  2.5  cm.  in  diametei',  and  an  interstitial  myo- 
ma which  had  undergone  almost  complete  hyaline  transformation.  The  central 
portion  of  this  had  broken  down   and  opened  into  the  uterine  cavity.     This 


SUPPURATING    UTERINE    MYOMATA. 


145 


cavity  on  histologic  examination  presented  the  typical  appearance  of  an  ab- 
scess wall. 

In  Case  14942  an  interstitial  myoma  had  been  detected  three  years  previously. 
Shortly  before  operation  the  patient  lost  26  pounds.  Fully  one-fourth  of  the 
interstitial  myoma  had  been  converted  into  an  abscess  sac  (Fig.  110). 

The  supi3urative  changes  in  Case  7158  were  very  extensive.  The  uterus  was 
apparently  about  the  size  of  that  of  a  five  months'  pregnancy.  As  the  hand  was 
passed  around  to  tlio  right  of  the  uml)ilicus  there  was  an  escape  of  several  ounces 


Fig.  110. — A  Suppuratinc  iNTicitsTniAi.  Mvoma.  (Vnat.size.) 
Gyn.  No.  14942.  Path.  No.  12963.  The  patient,  admitted  July  2,  1908,  w.as  thirty-six  years  old  and  had 
noticed  the  tumor  for  three  years.  Recently  she  had  had  much  pain  in  the  lower  abdomen  and  had  lost  20  pounds. 
At  operation  the  omentum  was  densely  adherent  to  the  uterus.  The  myomatous  uterus  reached  SJcm.  above  the 
umbilicus.  The  enlargement  was  due  chiefly  to  an  interstitial  and  partly  submucous  myoma,  9  x  12  .x  12.5  cm., 
occupying  the  anterior  wall.  Fully  one-fourth  of  the  myoma  consisted  of  an  abscess,  the  margins  of  which  were 
very  irregular.     The  patient  made  a  good  recovery. 

of  thick  green  pus  with  a  garlicky  odor,  'i'lic  uterus  was  a]iproximately  M)  \  H)  x 
12  cm.  It  was  everywhere  covered  with  vascular  adhesions.  On  IIk^  anterior 
surface  was  a  necrotic  area,  10x8  cm.,  greenish  in  color,  and  surrounded  by 
dense  adhesions.  Its  edges  were  very  irregular  and  tlu^  u(H'rotic  surface  was  ul- 
cerated to  a  depth  of  5  inin.  It  was  fioni  this  area  that  tlu>  pus  escaped.  The 
great  increase  in  size  of  the  uterus  was  dne  to  a  large  int(>rstitial  myoma  situated 
in  the  anterior  wall.  This  was  dark  blue  in  color,  and  at  the  jwint  at  which  the 
ulceration  was  noted  had  reacheil  the  peritoneal  surface.  Tlu^  tumor  was  soft 
and  pultaceous  in  character  and  eniille<l  an  olTeiisive  odor.  'i1i(>  uterine  cavity 
10 


146 


MVOMATA    OF   THK    UTFIRUS. 


was  11  cm.  in  length.  Tlie  anterior  wall  was  perforated  over  an  area  5  x  4.5  cm. 
(Fig.  113).  The  margins  of  this  opening  were  sharply  defined,  and  the  floor 
of  the  cavity  was  uneven  ami  co\-(M-ed  with  greenish-3Tllow  pus.  The  necrotic 
material  had  not  only  hi-oken  through  the  ]ieritoneal  surface,  hut  also  into  the 
uterine  cavity. 

Gyn.  No.  8767.     Path.  No.  4959. 
An     interstitial     u  t  e  r  i  n  (>    m  y  o  m  a     a  t    one    ji  o  i  n  t    pro- 
jecting   into    the    uterine    c  a  v  i  t  y     ( Fig.   Ill),    and    u  n  d  e  r  - 
going    il  i  s  i  n  t  e  g  r  a  t  i  o  n  ;    slight     p  (^  1  \-  i  c    adhesions. 


Fig.  111. — Slight  Suppuration  ok  ax  Ixtkrstitiai,  Myoma  with  Pkrforatiox  into  the  Uterixe  Cavity. 

a  nat.  size.) 
Gyn  No.  S767.  Path.  No.  4959.  Occujiying  the  posterior  wall  is  a  myoma  17  cm.  in  diameter,  a  ami  a 
indicate  the  extreme  depth  of  the  uterine  cavity.  At  the  ijoints  indicated  by  b  the  mucosa  had  liisappeared  and 
here  the  underlying  myomatous  tissue  was  brownish  in  color,  roughened  and  disintegrating.  On  microscopic  ex- 
amination this  tumor  was  found  to  have  undergone  marked  hyaline  degeneration  and  there  was  consiiierable 
polymorphonuclear  infiltration. 


1'^.  P.,  aged  forty-four,  colored.  .Vdmitteil  Ma}'  Ki;  tlischarged  June  15, 
1901.  Com])laint:  An  abdominal  tumor  and  swelhng  of  the  legs  and  ankles. 
Her  menses  began  at  fourteen  and  were  regular  up  to  seven  years  ago.  Since 
then  the  periods  have  been  too  fre([uent.  At  present  lileeding  comes  on  three 
or  four  times  a  month  and  varies  from  a  small  amount  to  a  flow  lasting  from 
eight  to  ten  davs.     She  has  had  ten  children  and  two  miscarriages.     For  nine 


SUPPURATING    TTEIUXK    MYOMATA.  147 

years  there  has  been  a  white,  non-irritatii\o;  (Uscharge,  more  profuse  after  the 
menses,  and  she  has  noticed  that  the  abdomen  has  l)een  enlarged.  The  patient 
says  the  tumor  at  the  present  time  is  much  smaller  than  it  was  two  years  ago. 
During  the  past  three  months  she  has  had  frequent  urination  and  painful  defeca- 
tion. For  three  years  she  has  had  edema  of  the  legs,  especially  of  the  left. 
Hemoglobin,  51  per  cent. 

Operation.  Panhysterectomy.  When  the  ])atient  was  discharged,  the  left 
leg  was  still  rather  edematous  and  i)ainful.  but  the  hem()glol)in  had  risen  to 
70  per  cent. 

Path.  No.  4959.  The  specimen  consists  of  a  globular  uterus,  18  cm.  in  di- 
ameter, and  also  of  the  lateral  structures.  The  great  increase  in  size  of  the  uter- 
us is  due  to  an  interstitial  myoma,  approximateh^  17  cm.  in  diameter,  occui)ying 
the  posterior  wall.  The  uterine  cavity  is  15  cm.  in  length  and  its  mucosa  is 
scarcely  1  mm.  in  thickness.  The  chief  point  of  interest  in  this  case  lies  in  the 
fact  that  at  one  point  in  the  posterior  wall  the  mucosa  over  an  area  7x5  cm.  has 
entirely  disappeared  (Fig.  Ill),  and  the  portion  of  the  myoma  projecting  through 
is  brownish  in  color,  somewhat  roughened  in  appearance,  and  disintegrating. 
The  myoma  itself  is  rather  soft.     The  appendages  offer  nothing  of  interest. 

Histologic  Examination. — The  mucosa  lining  the  uterine  cavity  is  perfectly 
normal,  save  in  the  vicinity  of  the  area,  where  the  myoma  projects  through.  As 
we  approach  this  the  mucous  membrane  becomes  thinner  and  thinner,  until  it 
disappears  and  the  myomatous  tissue,  which  has  undergone  almost  complete 
hyaline  degeneration,  forms  the  floor  of  the  cavity.  Scattered  throughout  the 
hj^aline  material  are  quite  a  number  of  polyniorphonuclear  leukocytes.  It  is 
astonishing  to  see  such  a  mild  degree  of  inflanunation  where  so  much  loss  of 
substance  has  taken  ])lace. 

Gyn.  No,  5093.     Path.  No.  1599. 

A  n  i  n  t  e  r  s  t  i  t  i  a  1  u  1  e  r  i  n  e  m  y  o  m  a  s  u  ]>  p  u  r  a  t  i  n  g  a  n  d 
opening  i  n  t  o  u  t  e  r  i  n  c  c  a  v  i  t  y   (Fig.  1 12). 

M.  B.,  aged  forty-three,  white,  single.  Admitted  March  \'2:  thscliarged 
May  3,  1897.  Tlie  patient  first  noticed  an  abdominal  tumor  six  years  ago. 
This  has  grown  steadily.  It  is  slightly  soi-e  during  the  meiisli'ual  ])eiiod,  and  at 
these  times  is  inciH^aseil  somewhat  in  si/,e.  ( )ii  examination  under  ethei'  the  lower 
part  of  the  alxloiiieii  is  Inund  lilled  with  a  liai'd.  nodular.  |)artly  mobile  luiuoi- 
about  the  size  of  a  utems  in  the  se\-entli  moiilh  of  |iregnancy. 

Operation.  Ilysteromyomectomy.  The  tunioi'  was  (leli\-ei'ed  with  gi'eat 
difficulty  and  was  exti-emely  \'asculai'.  ()ii  section  into  th(>  cerxical  canal,  a 
sti'eam  of  bi'owii  tenacious  mucus  poured  oul.  ()ne-lil'lli  (if  ihe  let'l  o\ar\'  was 
left  behind.  ( 'oiixalesceiice  was  interru|  it  ei  j  jiy  the  foi'nialioii  of  a  ]iel\ic  abscess, 
ueeessitating  drainage  through  the  x'agina.  'I'liere  was  also  slight  suppuration 
from  the  alxlominal  incisidn. 

Path.  \o.   i5!l9.     The  specimen  consists  of  the  eiilai'ged  uterus  to  which  the 


148 


MVO.MATA    OF   THE    UTERUS. 


right  tulx'  is  attached.  The  uterus  has  been  converted  into  a  globular  tumor, 
22  cm.  in  diameter.  The  posterior  surface  is  covered  with  numerous  vascular 
adhesions — the  anterior  is  smooth  and  glistening.  Occupying  the  anterior  uterine 
wall  is  a  large  myoma,  which  is  undergoing  necrosis.  The  uterine  cavity  has  lieen 
drawn  out  by  the  tumor;  it  is  16  cm.  in  length  and  5  cm.  in  breadth  at  the  fundus. 
The  jiostcrior  surface  of  the  uterine  cavity  is  smooth  and  glistening,  but  is 
almost  eiitiicly  devoid  of  mucosa,  the  atrophy  being  evidently  due  to  pressure. 
On  the  autciior  suiface  of  the  uterine  cavity  are  two  oval  areas  with  sharply 


Fig.  112. — .\  Suppurating  Interstitial  Myoma  Opening  into  the  Uterine  Cavity,     (i  nat.  size.) 
Gyn.  No.  5093.     Path.  No.  1,599.     The  uterus  had  been  converted  into  a  globular  tumor  22  cm.  in  diameter, 
the  increase  in  size  being  due  chiefly  to  a  large  myoma  occupying  the  anterior  wall.     At  a  and  b  the  myoma,  which 
was  partly  necrotic,  had  broken  through  into  the  uterine  cavity.     The  myomatous  tissue  forming  the  floor  of  these 
cavities  was  dark  bluish  red  and  necrotic,     c  is  a  small  polyp. 


circumscribed,  smooth  margins,  and  a  central  portion  consisting  of  dark,  bluish- 
red  necrotic  tissue  (Fig.  112).  The  larger  area  is  4  cm.  in  its  longest  diameter. 
The  mucosa  over  the  remaining  portion  of  the  anterior  wall  is  smooth,  but  much 
thinned  out. 

Gyn.  No.  5617.     Path.  No.  1962. 

A  sup  ])  u  r  a  t  i  n  g  interstitial  u  t  e  r  i  n  e  m  y  o  m  a  ;  chronic 
endometritis  ;    n  o  r  m  a  1    a  \)  p  e  n  d  a  g  e  s  . 

II.  .1.,  colored,  aged  forty,  married.  Admitted  October  IS;  died  October 
21,  ISUT.     The  patient  has  had  two  children.     For  the  i)ast  year  she  has  had 


SUPPURATING   UTERIXK    MYOMATA.  149 

an  almost  continuous  hcinorrhage,  at  times  oozing  in  character,  at  other  times  very 
profuse,  with  severe  pain.  The  flow  has  been  offensive.  Five  years  ago  she  began 
to  have  pain  in  the  left  side  and  a  year  later  noticed  a  tumor  in  the  abdomen. 
This  has  grown  steadily.  She  is  weak,  has  shortness  of  breath  and  occasionally 
severe  abdominal  pains. 

Operation,  October  21,  1897.  Hysteromyomectomy.  The  patient  was  very 
weak,  the  pulse  beuig  130  and  feeble  before  operation.  She  had  had  bronchitis. 
Chloroform  was  first  used,  and  the  respirations  stopped.  The  patient  was  re- 
suscitated and  ether  employed.  The  pulse  rose  to  168,  grew  weaker  and  weaker 
and  the  patient  died  on  the  talkie.  Her  temperature  before  operation  ranged 
from  99.8°  to  104.2°  F. 

Path.  No.  1962.  The  specimen  consists  of  the  uterus  and  its  appendages.  The 
uterus  is  globular,  resembling  the  pregnant  wom]3,  and  averages  22  cm.  in 
diameter.  Posteriorly,  it  is  covered  with  numerous  vascular  adhesions.  The 
under  cut  surface  is  7  cm.  in  diameter.  The  uterine  cavity  is  greatly  enlarged, 
being  nearly  22  cm.  long  and  13  cm.  broad  at  the  fundus.  The  posterior  wall 
averages  3  cm.  in  thickness,  but  the  anterior  wall  contains  a  tumor  17  cm.  in 
diameter.  This  is  in  part  covered  with  mucous  membrane  which  is  thinned 
out  and  hemorrhagic.  About  the  center  of  the  cavity  the  tumor  has  broken 
through  the  mucosa  over  an  area  10  cm.  in  diameter,  and  a  large,  ragged,  sloughing 
mass  fills  the  cavity.  The  mucosa  covering  the  posterior  wall  is  also  atrophic 
and  hemorrhagic. 

Histologic  Examination. — Cover-slips  from  the  necrotic  mass  show  a  few 
cocci  arranged  in  rows,  also  short  bacilli  in  clumps  and  two  or  three  in  a  row.  The 
surface  of  the  myoma  where  it  projects  into  the  uterine  cavity  shows  disinte- 
gration and  is  completely  necrotic,  consisting  of  homogeneous  granular  and  jworly 
stained  material  containing  polymorphonuclear  leukocytes  and  fragmented 
nuclei.  The  deeper  portion  of  the  myoma  contains  areas  of  coagulation  necro- 
sis. The  uterine  mucosa  presents  none  of  the  normal  elements,  but  consists 
of  granulation  tissue  made  up  of  young  connective-tissue  cells,  young  blood- 
vessels, which  rise  to  the  surface,  and  a  dense  zone  of  small  round  cells.  The 
surface  is  covered  with  leukocytes  embedded  in  fibrin. 

San.  No.  1847.     Path.  No.  8346. 

Diffuse  t  li  i  c  k  (•  u  in  g  o  f  t  li  c  u  t  c  r  i  u  c  wall:  s  u  p  ]•  u  r  a  I  i  o  n 
o  f    a  II    i  11  t  ('  r  s  1  it  i  a  1    111  >'  d  m  a  . 

W.  .!.,  white,  iiianicd,  agcil  tliiiM y-t'our.  A(linittc(l  March  1  :  discharged 
April  12,  1905.  The  i)atient  has  had  eleven  children  and  has  had  i)rofus(>  niiMi- 
struation  for  the  last  year.  She  is  very  sallow  in  apju'arance  and  has  a  hemo- 
globin of  50  jier  cent.  After  hysterectomy  the  patient  made  a  very  satisfactory 
recovery. 

Path.  No.  8316.  Tlie  specimen  consists  of  the  uterus,  which  is  about  twice 
its  natural  size.     This  case  is  reported  in  full  in  '' A  d  e  n  o  m  y  o  m  a   o  f    the 


150  MVOMATA    OK    THK    ITERUS. 

Uterus,"  p.  230.  Briefly,  it  consists  of  an  interstitial  myoma  which  has 
undergone  almost  comi)l('t(>  hyaline  transformation  and  then  sujipuration. 
On  histologic  examination  llic  iimer  surface  of  this  contains  many  polymor- 
]>li()iuicl(';ir  Icid^ocytes.  The  offensive  (hscharge  was  ('videiitl}-  (hie  to  the  de- 
generation. 

Gyn.  No.  7158.     Path.  No.  3431. 

A  1  a  r  g  e  interstitial  n  e  c  r  o  t  i  c  m  y  o  m  a  ;  [)  e  r  f  o  r  a  t  i  o  n 
of  t  h  e  u  t  e  r  u  s  ant  e  r  i  o  r  1  y  ,  f  o  r  m  a  t  i  o  n  o  f  a  h  s  c  e  s  s  on 
its  s  u  r  f  a  c  e  a  n  d  u  1  c  e  rati  o  n  i  n  t  o  the  uterine  cavity 
(  F  i  g  .  1  1  .">  )  ,  g  i  ^'  i  1'  g"  1"  i  •'^  ^'  to  a  p  u  r  u  lent  vagi  n  a  1 
(1  i  s  c  h  a  r  g  e. 

0.  S.,  aged  twenty-three,  white,  married  Admitted  August  26;  died 
August  29,  1S90.  The  ])atient  had  had  one  child  and  no  miscarriages.  She  was 
profoundly  emaciatecl  and  had  a  pulse  of  from  120  to  130;  the  temperature  varied 
from  100°  to  103°  F.     She  was  in  a  desperate  condition  when  put  on  the  table. 

Operation.  The  uterus  was  apparently  about  the  size  of  that  of  a  six  months' 
pregnancy.  \\  hen  the  hand  was  jjassed  around  to  the  right  of  the  umbilicus, 
there  was  a  free  escape  of  several  ounces  of  thick  green  ])us  having  a  distinctly 
garlicky  odor.  This  was  removed  as  fast  as  possible,  to  i)revent  general  infection. 
The  fundus  was  ch'awn  out  with  considerable  (hfficulty,  and  a  large  necrotic  area 
surrounded  by  adhesions  was  found  on  the  anterior  surface.  The  uterus  was 
removed  in  tiie  usual  way,  the  abdomen  (h'ained,  and  an  infusion  of  saline 
sokition  given.  The  patient,  however,  was  in  a  desperate  condition,  showed 
but  little  improvement,  and  died  on  the  third  day. 

Path.  No.  3431.  Tlie  sj)ecimen  consists  of  a  large  globular  myomatous 
uterus  with  its  tubes  and  ovaries.  The  uterus  is  approxhnately  19  x  16  x  12 
cm.  Over  its  entire  surface  it  is  injected  and  covered  with  vascular  adhesions. 
On  the  anterior  surface  is  a  necrotic  area,  10  x  8  cm.,  greenish  in  color  and  sur- 
rounded by  dense  adhesions.  The  edges  are  irregular  and  the  necrotic  surface 
has  ulcerated  to  a  depth  of  5  mm.  The  great  increase  in  size  of  the  uterus  is  due 
to  a  large  interstitial  myoma  situated  in  the  anterior  wall.  This  is  dark  blue 
in  color  and  at  the  jxjint  at  whicli  ulceration  was  noted  has  reached  the  peritoneal 
surface.  It  is  soft  and  {)ultace()us  in  consistence  and  emits  an  offensive  odor. 
The  myomatous  arrangement  is  still  visible.  The  uterine  cavity  is  11  cm.  in 
length  and  the  mucosa,  api)roximately  2  mm.  thick,  is  deeply  injected  and  in 
places  shows  a  yellowish-brown  mottling.  Situated  in  the  anterioi'  utei-ine  wall 
and  opening  directly  into  the  cavity  is  a  heart-shaped  ])ei-f()ration,  0  x  4.5  cm. 
(Fig.  113).  Its  floor  is  uneven  and  covered  with  greenish-yellow  jms.  Its  mar- 
gins are  slightly  raised  and  sharjjly  defined.  The  right  tulx-  is  coNcred  with 
adhesions.  Its  fimbriat(Ml  end  is  patent.  The  ovary,  apart  from  adhesions,  is 
normal.  The  apjn'ndages  on  the  left  side  are  likewise  co\-ered  with  adhesions, 
but  are  otherwise  unaltered. 

Histologic  Examination. — Sections  from  the  uterine  mucosa  neai-  the  opening 
in   the  anterior  wall  show  that   it   is  comjjosed  almost   entirely  of  granvdation 


Sri'PURATIXG    UTERIXK    MYOMATA. 


151 


tissue,  which  is  weh  oriiaiiizcd  ami  sliows  very  little  !)()lyiii()ri)hoiuiclear  infiltra- 
tion. Here  and  there  the  surface  ei)ithehuni  is  to  a  sli^iiht  extent  preserved,  but 
at  such  pomts  has  proliferated.  A  few  glands  are  still  visible,  but  in  most  of  them 
the  gland  contour  is  distorted  and  the  cells  stain  palely  and  are  swollen.  At  the 
edge  where  the  perforation  has  taken  place  the  surface  is  covered  with  polymor- 
phonuclear leukocytes,  and  the  tissue  consists  essentially  of  granulation  tissue 
devoid  of  gland  elements  and  containing  many  polymorphonuclear  leukocytes. 
The  floor  of  the  area  of  ulceration  consists  essentially  of  necrotic  myomatous 


Fu;.  113. — A  Largk  Suppurating  Intkkstitial  Myoma  Upp:nin(;  into  and  Infecting  the  Peritoneal  Cavity 
A.ND  ALSO  Drainini:  INTO  THE  Cavity  OF  THE  Uterus.     (i  nat.  sizc") 

Gyn.  No.  7158.  Path.  No.  34.'U.  The  uterus  was  ai)i)roxiniately  19  x  16  x  12  cm.  On  the  anterior  surface 
as  seen  from  the  history,  was  a  foul  necrotic  area  10  x  S  cm.,  where  tlie  myoma  had  ulcerateil  through  to  the  surface. 

At  a  the  myoma  had  ulcerated  through  into  the  uterine  cavity.  Tliis  cavity  measured  4..")  x  r>  cm.  and  its 
floor  was  covered  with  greenish-yellow  pus.  The  entire  myoma  was  dark  blue  in  color,  soft  and  pultaceous  in 
character,  and  emitted  an  offensive  odor. 


tissue  containing  nothing  but  fragmentated  polyiiKirithonuclear  leukocytes. 
Sections  from  the  outer  surface  of  the  uterus,  where  the  ulcerated  area  was  noted, 
show  necrotic  myomatous  tissue  coiitaiiiing  (|uaiitities  of  polym()r|)honuclear 
leukocytes.  It  is  interesting  to  note  thai  iiunierous  neci'otic  muscle  nuclei 
contain  calcareous  pl.'ilcs.  Sections  from  othci'  ]ioilions  <»f  the  myoma  show 
that  it  has  undergone  ahiiosl  coinplcic  coagulation  necrosis,  it  is  most  exceptional 
to  And  such  a  puncluMl-out  area  of  ulceration  comniunicating  with  the  uterine 
cavitv.      In  brief,  we  hnxc  a  laruje  necrotic  ni\-oni;i,  with  ulceration  on  its  anterior 


152  MYOMATA    OF   THE    UTERUS. 

peritoneal  surface  and  a  corresponding  area  of  ulceration  on  its  posterior  surface, 
coinnuinicatino;  witli  the  uterine  cavity  by  the  large  opening  above  mentioned. 

Cause  of  Suppuration  in  Uterine  Myomata. 

It  will  be  seen  that  suj^puration  in  interstitial  and  subperitoneal  myomata  is 
a  rare  occurrence.  In  the  majoritv  of  the  cases  hyaline  degeneration  is  present. 
This  is  chie  to  a  (hininishcd  blood-supply.  In  the  subperitoneal  variety  infection 
from  the  intestine  was  evidently  the  cause  in  three  of  the  cases.  Here  the  de- 
generated myomata  had  l)ecome  adherent  to  the  cecum  or  small  bowel.  As  the 
intestinal  nourishment  to  the  myoma  l)ecame  more  and  more  abundant,  the  inter- 
vening walls  gradually  became  thinner  and  thinner  until  the  cavity  in  the  myoma 
opened  directly  into  the  bowel.  The  constant  passage  of  feces  into  and  out  of  the 
myoma  cavity  naturally  converted  it  into  an  abscess-sac. 

In  those  cases  in  which  the  myomata  were  entirely  free  from  the  intestine 
hyaline  degeneration  had  likewise  evidently  first  taken  ])lace,  l)ut  why  they 
became  infected  later  it  is  difficult  to  say. 

Interstitial  myomata  that  impinge  on  the  uterine  cavity  are  easily  infected 
when  there  is  focal  necrosis  or  hyaline  degeneration  in  portions  of  the  myoma 
near  the  uterine  cavity  and  an  infective  agent  in  the  uterine  nmcosa.  Infection 
readily  follows  on  account  of  the  poor  blood-sui)]oly  of  the  average  myoma. 

Suppuration  in  a  myoma  must  not  be  confused  with  the  condition  in  such 
cases  as  A.  W.  (Path.  No.  S932),  wliere  there  were  tubo-ovarian  abscesses, 
and  as  a  result  secondary  and  encysted  abscesses  developed  in  the  spaces  between 
contiguous  myomata.  Here  the  purulent  process  was  confined  almost  entirely 
to  the  outer  surfaces  of  the  tumors  and  not  to  their  interiors. 

The  ap])earance  of  the  myoma  that  has  undergone  marked  hyaline  degener- 
ation very  often  simulates  abscess  formation  so  closely  that  it  is  impossil)le  to 
render  an  absolute  diagnosis  without  making  sections.  AMiere  simple  hyaline 
degencM'ation  is  i)resent,  no  nuclei  are  visible,  \\niere  abscess  formation  has  taken 
place,  the  characteristic  polymor])honuclear  leukocytes  are  in  evidence. 

Symptoms  of  Suppurating  Uterine  Myomata. 

With  the  advent   of  sui)purati()ii   in   the  uterine  myomata  the  symptoms 

may  undergo  a  marked  change.     A  sticking  or  lancinating  pain  is  noticed  in  the 

lower  abdomen,  and  the  patient  may  have  chills  and  fever,  at  times  accompanied 

by  night-sweats.     One  of  the  inoi-e  ini])or1ant  late  phenomena  is  the  sallow  color. 

This  differs  entirely  from  the  i)allor  that  is  so  fi-e(|uently  noted  where  there  has 

been  great  loss  of  blood  from  submucous  myomata.     If  such  septic  absorj)tion 

has  taken  ]ilace,  the  patient  often  grows  very  weak  and  the  tumoi-  may  a))j)arently 

diminish  somewhat   in   size.*     With   the  septic  absoi'ption   renal  changes  may 

*  Leukocytosis  in  niyonia  cases,  it'  there  is  no  oft'ensivc  uterine  disciiarge,  usually  indicates 
either  a  suppurating  myoma  or  a  purulent  accumulation  involving  the  tubes,  the  ovaries,  or 
both.     .\n  ordinurv  nivomatous  uterus  does  not  give  rise  to  a  leukocytosis. 


SUPPURATIXG   UTERINTE   MYOMATA.  153 

be  induced,  recognizable  by  the  ])resence  of  alhumiii  and  casts  in  the  urine. 
"V\liere  the  suppurating  myomata  open  into  the  uterine  cavity,  there  is  a  pro- 
fuse foul-snielhng  vaginal  discharge. 

Treatment. 
The  patient's  resistance  is  naturally  much  reduced,  and  the  pulse,  just  before 
operation,  may  be  very  rapid,  as  is  so  often  the  case  when  pus  is  present.  Our 
object  should  be  to  remove  the  uterus  just  as  soon  as  feasible,  as  without  operation 
the  condition  will  steadily  grow  worse.  In  these  cases  the  purulent  process  is 
usually  very  active,  and  consequently  the  dangers  of  infection  are  great. 

RESULTS   AFTER   OPERATION    FOR   SUPPURATING   INTERSTITIAL   OR   SUB- 
PERITONEAL MYOMATA. 

Gyn.  No.       12216 Died  of  intestinal  obstruction  on  sixth  day 

"       "  3216 Recovered. 

"       "  7549 Recovered. 

"       "  8767 Recovered. 

"       "  509.3 Recovered  (postoperative  pelvic  abscess). 

"       "  5617 Died  on  table  (desperate  condition  before  operation). 

"    S.    1847 Recovered. 

"       "  7158 Died  on  third  day  (peritonitis  before  operation). 

"       "  9078 Recovered. 

"       "        14942 Recovered. 

"       "        15281 Recovered. 

We  have  given  this  table  to  show  the  high  mortality  in  such  cases.  The  result 
in  Case  12216  is  open  to  criticism,  as  the  abdomen  should  have  been  explored 
earlier  and  the  obstruction  relieved.  In  Case  5617  the  woman  was  in  a  desperate 
condition  before  operation,  and  the  fatal  result  in  Case  7158  is  what  might 
naturally  have  been  expected.  In  the  majority  of  such  cases  it  is  well  to  drahi 
the  pelvis  through  the  vagina,  and  in  some  cases  also  from  above,  treating 
the  entire  pelvic  content  as  a  most  dangerous  area  of  infection. 


NECROTIC  MYOMATA. 

Necrosis  is  fairly  common:  it  is  liable  to  occur  in  sub]ieritoneal,  interstitial, 
or  submucous  myomata,  but  inorc  esi)ecially  in  sloughing  submucous  nodules. 
In  a  few  instances  we  have  noted  it  in  very  small  myomata,  but  it  is  more  prone  to 
develo|)  in  large  tumors. 

The  necrotic  areas  are  recognizerl  as  dirty  gray,  grayish-brown,  or  dark 
reddish-blue  patch(>s  in  the  myoma.  Such  areas  ar(>  clearly  outliiuMl.  but  the 
contrast  between  the  myomatous  tissue  and  th(>  degenerated  j)ortion  is  not 
nearly  as  clean  cut  as  in  the  cases  where  hyaline  degeneration  exists.  In  the 
necrotic  areas  the  muscular  striation  is  usually  still  visible,  Init  the  tissue  is  softiM* 
than  usual.  The  necrosis  is  usuall\'  in  the  ('(Mitral  portion  of  the  tumor,  but  is 
occasionallv  not(Ml  near  the  surface,  as  in  Case  lOSSo  (Path.  \o.  7()S<)).     It  mav 


154  MVOMATA    OF   THE    UTERUS. 

be  limited  to  one  area,  or  the  luyoiua  may  contain  several  foci  of  degeneration. 
Hvaline  d(>generation  and  neci-osis  are  often  noted  side  by  side  in  the  same  tumor. 

Histologic  Examination.— Where  the  necrotic  area  is  present,  the  muscle- 
fibers  usually  still  persist,  but  fail  to  take  the  stain.  As  a  rule,  the  fi(>ld  is  devoid 
of  any  living  cells,  but  occasionally  a  few  muscle  nuclei  may  still  be  visible  around 
the  blood-vessels,  as  noted  in  Case  3199  (Path.  No.  524).  In  a  few  cases  frag- 
mented nuclei  have  been  tletected  in  the  necrotic  area.  This  was  the  case  in 
Gyn.  No.  ::;199  (Path.  No.  524)  and  Gyn.  No.  3296  (Path.  No.  580). 

As  noted  on  page  127,  lime  salts  may  be  (le])osited  in  the  necrotic  areas. 

It  is  exceptional  to  note  any  inflannnatory  reaction  in  the  necrotic  areas, 
except  in  submucous  myomata.  Case  3199  (Path.  No.  524),  however,  proved 
an  exception,  as  some  polymorphonuclear  leukocytes  were  noted. 

The  coagulation  necrosis  is  undou])tedly  caused  by  a  partial  cutting  off  of  the 
myoma's  blood-supply. 


CHAPTER  X. 
MYOMATA  ASSOCIATED  WITH  MALFORMATIONS  OF  THE  UTERUS. 

We  have  encountered  three  cases  of  myoma  coming  inukn-  this  category: 

1.  Numerous  discrete  myomata  in  a  uterus  containing  two  (hstinct  uterine 
cavities  and  two  cervical  canals. 

2.  A  diffuse  adenomyoma  in  one  horn  of  a  bicornate  uterus. 

3.  A  submucous  adenomyoma  developing  in  a  uterus  in  which  there  was 
apparently  only  one  fundus,  with  a  septum  (Uviihiig  the  cervix  into  two  canals, 
and  a  double  vagina. 

Gyn.  No.  11694.     Path.  No.  7953. 

A  large  m  3^  o  m  a  t  o  u  s  tumor,  on  s  e  c  t  i  0  n  s  h  o  w  i  n  g  t  w  o 
distinct    uterine    cavities    (P'ig.  114). 

y.  H.,  aged  thirty-seven,  white,  single.  Admitted  Noveml^er  16;  discharged 
December  10,  1904.  The  patient  has  always  been  nervous  and  subject  to  con- 
stipation and  headaches.  One  year  ago  she  had  an  attack  of  vomiting  and 
sharp  pain  in  the  region  of  the  appendix.  She  noticed  a  lump  in  the  alxlomen 
at  that  time.  This  has  grown  until  it  has  reached  its  present  size.  On  ex- 
amination, the  pelvis  is  filled  with  a  large  multinodular  mass  reaching  10  cm. 
above  the  umbilicus.  At  operation  dense  adhesions  were  found  about  the 
j)ylorus  and  gall-bladder  and  in  the  region  of  the  ap])endix.  Hysteromyomec- 
tomy  was  performed. 

Path.  No.  7953.  The  uterus  contains  many  nodules  and  measures  approxi- 
mately 15  X  17  cm.  On  section,  two  definite  uterine  cavities  are  disclosed,  as 
seen  in  Fig.  114.     The  mucosa  lining  each  cavity  shows  little  or  no  cliange. 

Gyn.  No.  10314.    Path.  No.  6531. 

D  0  u  b  1  e  (•  e  r  v  i  x  ,  d  o  u  1)  1  e  vagi  n  a  :  s  u  b  111  u  c  o  us  adeno- 
myoma. 

E.  K.,  white,  aged  fifty,  married.  Admitted  March  7:  (hscharged  April  17, 
1903.  The  operation  consisted  in  si>littiiig  the  vagina  and  cervical  sei)tum  and 
in  the  I'cinox'ul  of  a  suiiinucous  iiiyoiiia. 

Path.  Xo.  ()5."!1.  The  myoma  is  appro.ximately  7\7\  11  ciii.  Scatt(Mvd 
tln'oughout  it  arc  iiunicroiis  ii-i'cgular  islands  of  mucosa  :  ;il  olln'i'  poiiils  ai'e  spaces, 
I'uHy  S  X  2  mm.,  Wwcd  wilh  imicosa  wliicli  almost  (•oiiiplclcly  lills  ilic  (■;i\il\'. 
These  ai'c  instaiillx'  ivcognizrd  as  tiiiniaturf  utci-iiic  caxMtics.  Sonic  of  these 
spac(\s  are  pale  ainl  lillcd  wilh  (■hocoj.atc-coioi'cij  contents  cN'idcntly  old 
menstrual  blood. 

155 


156 


MYOMATA    OF   THE    UTERUS. 


Fig.  114, 


MYOMATA    ASSOCIATED    WITH    MALFOR.MATlUXS    OF   THE    UTERUS.  157 

The  growth  on  histologic  oxaniiiiation  presents  tlie  typical  adenoniyomatous 
appearance.  It  is  described  m  detail  in  "  A  d  e  n  o  ni  y  o  m  a  of  t  h  e  U  t  e  r  u  s," 
p.  162  (Fig.  47). 

Gyn.  No.  11572.     Path.  No.  7800. 

Diffuse  a  d  e  n  o  ni  y  o  m  a  in  one  horn  of  a  b  i  c  0  r  n  a  t  e 
uterus. 

This  case  is  also  described  in  detail  hi  "  Adenoniyonia  of  the  Uterus,"  p.  238. 

It  is  mteresting  to  note  that  in  two  out  of  the  three  cases  in  which  myomata 
were  associated  with  an  al)normal  develoi)ment  of  the  uterus  the  growths  were 
of  the  adenoniyomatous  type. 

Fig.   114. — A  Double  Uterus  Containing  Subperitoneal,  Interstitial,  and  Submucous  Mvomata. 

(f  nat.  size.) 
Gyn.  No.  11694.     Path.  No.  79.53.     This  tumor  reached  10  cm.  above  the  umbilicus,  and  measured  15  x  17  cm. 
Two  distinct  uterine  cavities  are  seen  and  two  separate  cervical  canals  (a,  b).     Scattered  throughout  the  uterus 
are  many  interstitial  nodules,  and  projecting  slightly  into  the  cavity  is  a  submucous  myoma.     Several  myomata 
project  from  the  outer  surface  of  the  uterus. 


CHAPTER  XI. 
ANGIOMYOMA. 

The  hlood-supply  of  a  inyoina  may  be  so  copious  that  the  tumor  in  reality 
becomes  an  ano-iomyoma.  This  excessive  vascularity  is  occasionally  noted  in 
the  dependent  portions  of  subnmcous  myomata;  it  may  also  occur  when  a  sub- 
peritoneal pedunculated  myoma  has  become  twisted.  In  a  few  cases  we  have 
seen  the  angiomyomatous  appearance  totally  independc^it  of  any  interference 
with  the  blood-supph\ 

In  Case  3449  (Path.  Xo.  6S3)  the  uterus  was  irregularly  lilobular  and 
measured  13  x  13  x  14  cm.  Situated  in  the  anterior  wall  was  a  dark-red  and 
very  vascular  myoma,  10.5  x  12  cm.  Sections  from  this  tumor  showed  that  the 
dark  color  was  due  to  the  angiomyomatous  character  of  portions  of  the  myoma. 

In  Case  3357  (Path.  No.  618)  the  uterus  contained  a  myoma  6.5  cm.  in 
diameter.  On  histologic  examination  it  was  found  that  the  tumor  had  a  very 
rich  ca})illary  blood-supply.  So  abundant  were  the  capillaries  that  the  muscle 
was  everywhere  divided  up  into  small  irregular  squares  by  them. 

In  Case  7226  (Path.  Xo.  34S6)  the  multinodular  ut(>rus  was  approxhnately 
13  cm.  in  diameter.  The  largest  pedunculated  tumor,  both  m  shape  and  color, 
bore  a  striking  resemblance  to  a  spleen.  It  was  7  x  9  x  12  cm.  and  attached 
to  the  uterus  by  a  delicate  pedicle,  1.5x0.7  cm.  On  section,  the  nodule  pre- 
sented a  dark,  reddish-brown,  glistening  appearance.  On  histologic  examination 
it  showed  large  areas  of  coagidation  necrosis  accom])anie(l  l)y  hemorrhage,  and 
in  the  degenerated  areas  the  blood-vessels  were  much  dilated  (Fig.  115).  It 
was  only  in  the  outlyhig  portions  of  tlie  growth  that  typical  myomatous  tissue 
was  preserved. 

In  Case  3488  we  have  a  remarkable  example  of  a  myoma  showing  numerous 
large  angiomyomatous  foci. 

Gyn.  No.  3488.     Path.  No.  707. 

A  n  g  i  o  m  y  o  m  a   o  f   t  h  e   u  t  c  r  u  s    (Figs.  116  and  117). 

A.  D.,  married,  aged  forty-five,  white.  Admitted  May  7;  discharged  June 
3,  1895.  Five  years  ago  the  ])atient  noticed  enlargement  of  the  abdomen 
accompanied  by  l)earing-(l()wn  ])ain.  The  swelling  has  gradually  increased. 
The  mass  is  movable,  but  not  tender.  The  patient  has  a  tlragging  sensation 
in  the  lower  abdomen.     A  successful  hysterectomy  was  done. 

Path.  Xo.  707.  The  uterus  is  25x20x15  cm.  It  is  smooth,  and  sj^ring- 
ing  from  the  under  surface  on  the  left  side  is  a  nodule,  5  x  3  cm.     The  uterine 

1.58 


Fig.  116. — Mi-ltiple  Angiomatous  Fori  in  a  Mvoma.     (^  nat.  size.) 

Gyn.  No.  3488.     Path.  No.  707.     A  section  through  an  interstitial  myoma,   15  x  20  x  22  cm.      Scattered 

throughout  the  tumor  are  groups  of  cysts  originating  in  the  melting  of  hyaline  material.     At  numerous  points  are 

sharply  outlined  dark-red  or  bluish  porous  areas.     These  consist  almost  entirely  of  blood-vessels,  chiefly  arteries. 

This  is  the  only  myoma  that  we  have  ever  seen  presenting  such  pronounced  and  circumscribed  angiomatous  areas. 

For  the  histologic  appearance  see  Fig.  117.     (After  Howard  A.  Kelly.) 


AXGIU.MYU.MA. 


159 


cavity  is  10  cm.  in  loiigtli;  its  walls  average  2  cm.  in  thickness;  the  uterine 
mucosa  is  whitish  in  color,  smooth  and  glistening,  and  projecting  into  the 
utenne  cavity  from  the  jKJsterior  wall  near  the  cervix  is  a  sessile  nodule. 
2.5  X  1.5  X  1  cm. 

Occupying  the  left  uterine  wall  is  a  tumor  approxhnately  15x20x22  cm. 
On  section  this  is  whitish  yellow  in  color  and  consists  of  fibers  concentricalh* 
arranged.  Scattered  throughout  the  tumor,  especially  in  its  central  i)ortion, 
ai-e  numerous  dark-blue  vascular  areas,  comj^osed  of  l)lood-vessels  (Fig.  116). 
These  vascular  areas  present  a  honeycombed  api)earance  and  vary  from  0.5  to 
3.5  cm.  in  diameter.     The  individual  vessels  are  closely  packed  together.     Some 


Fig.   115. — Angiomyoma.      (X  120  diaiu.') 
Gyii.  No.  7226.     Puth.  No.  .3486.     The  section  is  from  a  peduiicnilated,  siilccn-.shaped,  dark  reddish-brown,  sul)- 
Ijeritoneal  myoma.     At  a  the  muscle-fibers  are  still  clearly  seen.     M  b  the  tissue  has  become  rarefied.     Scattered 
throughout  the  field  are  many  dilated  veins  (c). 


are  not  larger  than  a  ])in-])oint,  others  reach  'A  mm.  in  diameter.  The  vessel-walls 
are  smooth  and  glistening.  The  entire  ))ictiire  suggests  an  angioma.  The  tumor 
has  undergone  a  niodei-ate  amount  of  cystic  degenei'atioii.  The  cysts  ;ii-e 
scattei'cd  iifegularly  thi-oughout  the  tissue,  and  \ai-y  from  ().;;  to  .")  cm.  in 
diameter,  ha\-e  ifivgular,  shai-])ly  detined  edges,  ;uid  conlain  a  pale  \-elIo\v 
transj)arenl  Ihiid  which  coagulates  on  e\posui-e  to  the  air.  The  sm.aller  c\sts 
are  commencing  to  merge  one  into  the  olhei-.  and  one  of  ilie  lar^e  (vn'ities 
contains  an  ii'ivgulai',  xcllowisli-white  mass,  .'!  cm.  in  di.ameiei',  in  its  center. 
This  is  held  ill  |»osilioii  by  delicate  bands  which  aic  adhei-eiil  lo  the  margin  of 
the  ca\ity.  '|"he  walls  of  this  ca\ily  are  smooth  and  glistening,  and  numerous 
delicate  blood-Ncssels  c;in  be  seen  raniif\in<2;  beneath   the  surface. 


160  MVOMATA    OY   THE    UTERI'S. 

The  outer  surface  of  \\\v  tumor  has  a  delicate  cai)sule,  yellowish  white  in  color, 
and  loosely  connected  with  the  uterine  muscle,  thus  allowing  the  tumor  to  be 
shelled  out  with  ease. 

Histologic  J'^xamination.— The  uterine  mucosa  has  been  imperfectly  preserved, 
but  where  present,  the  glands  are  oval  on  cross-section  and  have  an  intact 
epithelial  lining:  some  are  considerably  dilated.  The  stroma  of  the  nmcosa 
shows  small-round-celled  infiltration. 

The  lartre  tumor  situated  in  the  uterine  wall  is  composed  of  non-striped  nmscle- 


■>:1'^^_ 


'f!,_ 


fe^':-.  ....  ::^--:-l;li  .     '  if'  '"^MM 


iV'i. 


•..■\* 


iMf^^f'' 


i^ 


^ 

M 


Fig.  117. — Angiomyom.\.     (X  13  diain.) 
Gyn.  No.  3488.     Path.  No.  707.     The  section  is  from  one  of  the  angiomatous  areas  in  Fig.  116.     The  ground- 
work consists  of  typical  myomatous  ti.ssue,  well  seen  at  a.     Scattered  throughout  the  field  are  masses  of  arteries, 
some  of  them  large   (6).     The  tissue  immediately  surrounding   them  shows  some  hyaline  degeneration.     The 
muscle  is  here  and  there  undergoing  liquefaction  (c). 

fibers  arranged  in  bundles  and  cut  lx)th  longitudinally  and  transversely.  The 
tis.sue  has  a  rich  })lood-sui)})ly.  The  dark-blue  angiomatous  areas  are  com- 
posed almost  entirely  of  arteries  irregular  in  contour  (Fig.  117).  They  have 
an  endothelial  lining  and  a  thick  layer  of  circular  muscle  surrounding  them, 
but  the  greater  part  of  the  circular  layer  has  undergone  hyaline  degeneration, 
contrasting  sharply  with  the  surrounding  muscle.  Most  of  the  vessels  are  filled 
with  blood.  Scattered  throughout  the  tumor,  frociuciitly  in  the  vicinity  of  the 
blood-vessels,  are  irregular  areas  of  hyaline  tlegeneration.     In  some  of  these 


AXGIOMYOMA,  161 


hyaline  areas  an  isolated  small  round  cell  is  here  and  there  visible  and  in  a  few 
places  aggregations  of  small  round  cells  can  be  made  out.  In  the  area  where  the 
softening  has  occurred  the  tissue  has  undergone  practically  complete  hyaline 
degeneration,  but  a  muscle-fiber  can  here  and  there  be  seen  in  the  hj^aline  material. 
We  have  here  subperitoneal  and  submucous  myomata  and  a  very  large 
angiomyoma. 


11 


CHAPTER  XTT. 

LIPOMYOMA  OF  THE  UTERUS. 

A  tumor  of  this  character,  as  the  name  implies,  consists  of  myomatous  muscle 
interspersed  with  adipose  tissue.  Myomata  of  this  nature  are  exceedingly 
rare;  in  our  entire  series  only  one  typical  example  was  found.  This  case,  San. 
No.  8.')().  was  reportcnl  in  detail  by  Dr.  J.  H.  Mason  Knox,  .Ir..*  who  also  reviewed 


^mucowi  polyp 


utexinc  saviCy 


Vi(..  118. — LipoMYOMA.  (J  nat.  size.) 
San.  No.  Sl?ti.  Path.  No.  3703.  Tlie  uterus  has  been  amputated  through  the  cervix.  OccuijyiiiK  the  poste- 
rior wall  and  distorting  the  uterine  cavity  is  an  interstitial  myoma.  The  coarse  fibrillated  arrangement  of  the 
myomatous  growth  is  easily  seen,  but  the  interspaces  are  darker  in  color  and  more  homogeneous  than  usual.  They 
consist  to  a  great  extent  of  adipose  tissue  (Fig.  119).  The  uterine  cavity  is  much  lengthened;  at  the  fundus  is 
a  broa<l-ba.sed  polyp.     f.\fter  .T.  H.  Ma-son  Knox,  .Jr.) 

the  inca<;cr  literature  on  the  subject.  At  first  si^ht  the  iiiyoiua  presented  the 
usual  appearance,  hut  on  careful  sci'utiny  it  was  found  to  iiave  a  yellowish  tinge, 
and  although  in  many  places  the  coarse  fibrous  arrangement  of  the  myomatous 
tissue  could  be  readily  seen,  in  the  interspaces  the  tissue  was  more  homogeneous 

♦Johns  Hop!  ins  Hosp.  Jiull.,  liHU,  vol.  \ii,  p.  .JIS. 
I(i2 


LIPOMYOMA    OF    THK    ITKUL'S. 


163 


than  usual  (Fig.  118)  and  from  the  cut  surfaces  many  oil-globules  could  be 
brought  away  with  the  knife-blade.  On  pressure  the  myoma  felt  very  soft, 
although  it  showed  no  areas  of  degeneration. 

The  histologic  picture  is  characteristic.  The  many  clear  spaces  represent 
adipose  tissue,  and  the  framework  of  the  tumor  consists  essentially  of  non-striped 
muscle-fibers  (Fig.  119). 

In  two  other  cases  in  which  large  myomata  were  present  we  also  found  areas 
of  adipose  tissue  distributed 
throughout    the  tumor   (Fig.  a 

120,  J).  164:  Fig.  121,  p.  165). 


Ji>i  ^,^  ;.;•  v. 


-j::':-'W 


San.  No.  836.    Path.  No.  3703. 

L  i  j)o  m  y  o  m  a   o  f   t  h  e 
u  t  erus    (Figs.  118,  119). 

The  patient  was  sixty-two 
years  of  age  and  had  had 
thirteen  children.  The  labors 
were  normal.  The  meno- 
pause had  occurred  twelve 
years  previous  to  her  admis- 
sion. Three  years  later  she  ^' 
had  noticed  a  slight  serous 
vaginal  discharge,  which  soon 
disappeared,  but  returned 
after  an  interval  of  eight 
years,  only  lasting  a  short 
time.  I'oi-  two  weeks  she 
had  been  bleeding  moderately 
but  continuously.  0})era- 
tion,  iiysteromyomectomy. 

Path.     No.     370:-;.       Tile 


•..v../ 


1; 


\A. 


7>'-V 


6^-b 


K  J:A)'i^,J'-~Jt-Sei!)^(^- 


J 


Fig.  119. — Lipomvoma.     (X  48  diam.) 

San.    No.    836.     Path.    No.    3703.     The    section    is    from    the 

myoma  .seen  in  Fig.  118.     a  indicates  large  and  small  l)lood-vessels. 

The  solid  areiLs  (())  consist  of  myomatous  tissue,  and  the  many  clear 

spaces  (c)  represent  fat-cells.     .\11  |)arts  of  the  tumor  that  were  pre- 

SpeCimen     consists    ot     the    en-        served  presenteil  a  similar  picture,      i  After  .1.  H.  Ma,son  Knox,  .Jr.) 

larged  uterus,  both  F;ill()j)iaii 

tubes,  a  ])()rti()n  of  the  left  ox-ary.  and  a  cystic  right  (»\aiT.  The  utei-iis  is 
globular  in  form  ( Mg.  IJS),  regular  in  oulline,  M  x  b")  x  IS  cm.  in  its  various 
diameters.  It  is  peii'eetly  smooth.  The  uteiine  ea\it\-  is  I  1  cm.  in  length.  The 
muco.sa  of  the  anterior  wall  is  scarcely  I  mm.  in  thickness.  That  covering  the 
posterior  wall  is  considerably  alteicd:  in  some  places  minute  sj)aces  are  .scattered 
throughout  the  muco.sa,  .some  reaching  2  mm.  in  diameter.  Over  an  area  4x1 
cm.  in  the  uppei"  part  of  the  cavity  the  muco.sa  is  e\cessi.vely  thin  and  the  tumor 
lias  extended  almost  thi-oughthe  mucosa.  Situated  in  the  ui)|)ei-  i)art  of  the  cavity 
is  a  .sessile  |>ol\'|),  .">  x  2..')  cm.  ()ccu|)ying  the  posteiior  wall  is  ;i  tumor  mass, 
10  \  10  X  1.'!   cm.      (  )ii    section,    the     luinoi'   ;it     (irst    sight     preseuts     the   usual 


164 


MYO.MATA    ()P^   THK    UTERUS. 


appearance  of  myoma,  but  on  careful  scrutiny  is  found  to  l)e  markedly  different. 
Traversing  it  in  all  directions  are  <:;listcnint!;  bands,  between  which  are  yellow, 
soft-looking  areas.  A\'hen  the  cut  surface  is  scraped,  distinct  oil-globules  can  be 
brought  away — which  is  never  possible  when  an  ordinary  myoma  is  examined. 


Fio.  120.— LiPOMYOMA.     (X  140  diam.) 

Gyn.  No.  3133.  Path.  No.  494.  o  is  a  longitudinal  section  of  a  blood-vessel.  Surrounding  it,  and  embedded 
in  the  myomatous  tissue,  are  many  fat-cells  indicated  by  spaces. 

It  looks  very  much  a,s  if  the  vessel  when  it  first  entered  the  tumor  carried  a  certain  :unii\int  of  adipose  tissue 
with  it. 


The  tumor  presents  no  areas  of  breaking  down.     It  is  sharply  dehned  from  the 
surrounding  uterine  muscle.     It  varies  from  W  to  5  mm.  in  thickness. 

Ivight  side:    The  Fallopian  tube  is   considerably  lengthened   and  covered 
with  adhesions.     Its  fimbriated  extremity  is  adherent.     The  ovary  has  been 


LIPOMYOMA    OF    THE    UTERUS. 


165 


converted  into  a  lobulated,  partly  cystic,  mass,  wliich  measures  8x5x4  cm. 
The  outer  cystic  portion  consists  of  small  multilocular  cysts. 

Left  side:  The  tube  presents  the  same  appearance  as  the  right. 

Histologic  Examination. — The  uterine  tumor  is  found  to  consist  of  large  fat 
cells  inclosed  in  a  supporting  substance  consisting  of  smooth  muscle  and  con- 
nective tissue  in  varying  proportions  (Fig.  119).  The  fat-cells  are  generally 
round  (c),  oval,  or  irregular  in  outline  from  pressure.  They  vary  in  size  from 
five  to  fifteen  times  the  diameter  of  a  red  blood-corpuscle  and,  after  hardening 


b 


Fig.  121. — Lipomyoma.     (X  140  diam.) 
Gyn.  No.  .3320.     Path.  No.  589.     The  space  a  indicates  an  oblique  section  of  a  blood-vessel,     h  is  ordinary 
myomatous  ti.ssue.     .\t  numerous  points  are  aKKreRutions  of  fat-cells  (,c).     Surrounding  the  fat,  and  separating  it 
from  the  myomatous  tissue,  is  a  varyitiK  ;inii>uiit  of  fibrous  tissue  (d). 


by  llic  usual  pi'occss  in  which  the  fat  is  dissohcd,  apiw'ar  as  clear  spaces.  The 
nuclei  of  these  cells  can  fre(|ueiilly  be  made  out  as  oxal  or  r()(l-sha|)ed  bodies 
pu.shed  to  the  j)en])hery  and  often  situated  in  an  angle  between  other  cells. 
The  tumor  is  traversed  by  numerous  bands  of  firm  fibrous  ti.ssue  which  })roduce 
the  lobulated  ap])earance  notetl  in  the  gro.-;s  specimen.  The  tumor  consists 
esvsentially  of  non-striped  muscle-fibers  ;ind  fat-cells  e(|ually  intermingled.  There 
is,  of  course,  the  ground-work  of  fibrous  ti.ssue.  Scatteivd  thioughout  the 
tumor  are  large  cells  which  clo.sejy  resemble  mast-cells. 


166  .MVOMATA    OF    THK    UTERUS. 

Gyn.  No.  3133.     Path.  No.  494. 

A  r  (•  a  s    of    a  d  i  p  u  .<  (,'    l  i  .s  .s  u  e    i  11    a    111  y  o  in  a   (Fig-  1-Oj. 

M.  R.,  aged  fifty,  white.  Admitted  October  24;  discharged  November  24, 
lcS94.  The  .specimen  consists  of  a  pear-shaped  ntenis,  32  x  32  x  36  cm.  The 
great  increase  in  size  is  caused  by  an  interstitial  myoma.  The  mucosa  is  atrophic 
and  projecthig  nito  the  cavity  is  a  deHcatc  polyp.  Numerous  cystic  areas  are 
scattered  throughout  the  m3'0ma. 

On  histologic  examination,  in  addition  to  much  hyaline  tissue,  small  areas 
of  adipose  tissue  are  recognized.  In  one  group  may  be  anywhere  from  three  to 
eight  or  more  fat-cells,  chiefly  found  in  close  proximity  to  the  blood-vessels 
(Fig.  120),  and  reseml)ling  ordinary  adipose  tissue. 

Gyn.  No.  3320.     Path.  No.  589. 

Areas     of     adipose     t  i  s  s  u  e     i  n     a     m  y  o  m  a   (Fig.  121). 

M.  I).,  aged  twenty-nine,  white.  Admitted  February  8;  discharged  March 
9,  1895.  The  uterus  was  large  and  nuiltinodular.  The  largest  myoma  was 
13  X  21  X  28  cm.  Some  of  the  nodules  show  nmch  hyaline  degeneration  and 
liquefaction.     In  several  sections  small  groups  of  fat-cells  were  found  (Fig.  121). 


CHAPTER  XIII. 
ADENOMYOMA  OF  THE  UTERUS. 

In  1903,  in  a  review  of  the  literature  published  in  a  supplement  to  Orth's 
Festschrift,  one  of  us  (Cullen)  reported  22  cases  of  adenomyoma  examined  by  us 
up  to  that  time.  Sinee  then  we  have  paid  especial  attention  to  these  growths 
and  have  been  astonished  at  the  striking  frequency  with  which  they  occin-. 
Out  of  a  total  of  1283  cases  of  myomata  examined  from  April  1,  1893,  until 
July  1,  1906,  73  (about  5.7  ])er  cent.)  were  instances  of  adenomyoma.  We  have 
included  only  interstitial,  sub})eritoneal,  and  submucous  adenomyomata  and 
large  adenomyomata  of  the  uterine  horns. 

Our  cases  have  yielded  many  interesting  histologic  and  clinical  data.  It 
was  found  impossible  to  do  the  subject  justice  and  at  the  same  time  keep  the 
present  work  within  a  reasonable  size.  To  adenomyoma  accordingly  a  sepa- 
rate volume  has  been  devoted,  and  we  will  here  merely  give  the  briefest  sunmiary 
of  the  findings  which  have  l)een  fully  elaborated  in  that  publication.* 

Summary. — In  cases  of  adenomyoma  of  the  uterus  we  usualh'  find  a  diffuse 
myomatous  thickening  of  the  aterine  muscle.  This  thickening  may  be  confined 
to  the  inner  layers  of  the  anterior,  posterior,  or  lateral  walls,  but  in  other  cases 
the  myomatous  tissue  completely  encircles  the  uterine  cavity. 

This  diffuse  myomatous  tissue  contains  large  or  small  chinks,  and  into  these 
the  noriii;il  uterine  mucosa  flows.  If  the  chinks  are  small,  there  is  only  room 
for  isolated  gltmds,  but  wliei'e  the  spaces  are  of  goodly  size,  large  masses  of 
mucosa  How  into  and  fill  them.  We  accordingly  have  a  diffuse  myomatous 
growth  with  normal  nnicosa  flowing  in  all  directions  through  it.  The  nuicosa 
lining  the  uteiine  ca^■ity  is  perf(>ctly  noiinal. 

After  a  time  poitioiis  of  the  diffuse  myoma  may  be  iii])|)ed  off  and  be  eai'iMed 
toward  either  the  outer  or  inner  sui-faces  of  the  uterus.  It'  they  become  sub- 
!uuc()us  growths,  they  are  gradually  expelled.  If  they  i)ass  toward  the  outer 
sui'face,  they  become  eithei'  subperitoneal  or  int  laliganientary.  WC  lia\"e 
accordingly  diNideil  adeiioniyi  iiiala  into  the  following  groups: 

1.  .Vdenoniyomala  in  which  thenterus  pi-eseixcs  a  relatixcly  normal  contour. 

2.  Suhpei'itoneal  oi'  int  raliganienlary  adenomyomata. 

3.  Snl)inucous  adenomyomata. 

,\  dil'luse  adenomyoma  presents  a  \-ei-y  coaise  appearance,  because  the 
myomatous  musclc-bnndles  nni  in  all  dii-cctions.  In  the  spaces  between  bim- 
dles,   and   occasionally   siu'roumled  by  circular    rings  of  muscle,  we  find  spaces 

*  .Adoiioinyonri  nf  tlic  t  ■|('rus. 'riioiiiMs  Stc|)li(Mi  ( 'iillcii.  ]>.  JTO.  W.  ]^.  Sauiidcrs  Co.,  1908. 

If ',7 


168  MYOMATA    OF   THE   UTERUS. 

filled  Avith  tran.slucoiit  and  slightly  punctiform  tissue — areas  of  uterine  mucosa. 
Sometimes  its  direct  connection  with  the  mucosa  of  the  uterine  cavity  can  be 
traced.  Not  infrequently  cyst-like  spaces  are  scattered  throughout  the  diffuse 
myoma.  These  are  filled  with  a  chocolate-colored  fluid  and  arc  lined  with  a 
definite  membrane,  often  1  to  2  mm,  thick.  They  are  miniature  uterine  cavities, 
and  the  chocolate-colored  fluid  is  old  menstrual  blood  that  has  not  been  able  to 
escape. 

"When  an  adcnoniyoiiialous  nodule  becomes  subperitoneal,  the  menstrual 
flow  in  the  growth  may  gain  the  U}iper  hand  and  the  myoma  become  cystic,  the 
contents,  of  course,  being  formed  from  the  accumulation  of  old  menstrual  blood. 

Age. — Our  youngest  patient  was  nineteen,  o»iu-  oldest  sixty.  The  disease 
is  most  prevalent  between  the  thirtieth  and  sixtieth  years;  it  does  not  in  any  way 
tend  to  sterility. 

Symptoms. — Lengthened  menstrual  periods  are  the  first  symptoms.  The 
flow  gradually  assumes  the  proportions  of  hemorrhages  and  eventually  the  periods 
may  become  continuous. 

At  the  period  there  is  often  discomfort,  and  occasionally  a  grinding  pain  in  the 
uterus,  evidently  due  to  the  increased  tension,  since  all  the  islands  of  mucosa 
scattered  throughout  the  diffuse  myoma  naturally  swell  up  at  the  menstrual 
period  and  thus  increase  the  size  of  the  organ. 

In  over  two-thirds  of  our  cases  there  was  no  intermenstrual  discharge.  This 
is  perfectly  natural,  as  in  these  cases  the  uterine  mucosa  is  normal  and  no  dis- 
integration of  tissue  is  going  on. 

Clinically,  the  diagnosis  of  diffuse  adenomyoma  is  relatively  easy,  for  the 
following  reasons : 

1.  The  bleeding  is  usually  confined  to  the  period. 

2.  There  is  usually  much  })ain,  referred  to  the  uterus,  at  the  period. 

3.  There  is  usually  no  intermenstrual  discharge  of  any  kind. 

4.  The  uterine  mucosa  is  perfectly  normal,  and  may  be  rather  thick. 

No  other  pathologic  condition  of  the  uterus,  as  a  rule,  gives  this  characteristic 
picture.* 

Treatment. — The  patient's  health  is  often  gradually  undermined  by  the 
uterine  hemorrhages,  and  the  only  way  to  control  them  is  to  remove  the  uterus. 
A  supravaginal  hysterectomy  is  all  that  is  necessary.  The  ovaries  should  be 
saved. 

The  prognosis  is  good,  as  the  glands  of  the  adenomyoma  are  perfectly  normal 
uterine  glands  and  are  surrounded  by  the  characteristic  stroma  of  the  mucosa. 

Origin. — The  glands  in  the  adenomyoma  originate,  in  the  vast  majority  of  the 
cases  at  least,  from  the  uterine  nmcosa. 

Cause. — The  cause  of  adenomyoma  is  still  unsolved. 

*  Some  submucous  myomata  are  accompanied  by  a  train  of  symptoms  closely  resembling 
adenomyoma. 


CHAPTER  XIV. 
MYOSARCOMA  OF  THE  UTERUS.* 

That  a  primary  sarcomatous  change  can  take  place  in  a  myoma  has  long  been 
kno\Mi,  and  as  early  as  1863  Virchowf  gave  a  very  clear  account  of  the  gross  and 
histologic  pictures.  In  1872  ChrobakJ  again  drew  attention  to  this  class  of 
cases,  and  in  1887  Ritter§  gave  a  full  abstract  of  the  literature  up  to  that  date. 
In  1894  the  same  question  was  fully  discussed  by  Williams  ||  and  also  by  Schreher,^ 
and  in  1895  L.  Pick**  gave  a  very  clear  account  of  sarcomatous  changes  in 
myomata.  The  article  by  Gessnerft  published  in  1899  is  most  exhaustive  and 
will  well  repay  a  thorough  study.  Among  the  still  more  recent  and  lucid  articles 
are  those  of  Weir,Jf  published  in  1901,  and  of  Jacobi  and  Wollstein,§§  which 
appeared  in  1902. 

Frequency. — Although  quite  a  number  of  isolated  instances  of  sarcomatous 
changes  in  myomata  have  been  recorded,  it  would  appear  that  the  importance 
of  the  subject  has  hardly  been  fully  appreciated.  Fehling,  ||  ||  in  409  myomata, 
found  that  2  per  cent,  showed  malignancy.  In  eight  there  was  a  sarcomatous 
degeneration  and  in  one  case  carcinoma  was  present  in  the  same  uterus.  Martin*}^ 
observed  direct  sarcomatous  transformation  four  times  in  a  series  of  205  cases. 

*  The  term  myosarcoma  may  be  objected  to  on  the  ground  that  in  some  cases  it  is  impossible 
to  say  whether  the  sarcoma  has  developed  from  the  myomatous  muscle  or  from  its  connective 
tissue.  We  fully  appreciate  this  objection,  but  since  in  the  great  majority  of  our  cases  the  origin 
of  the.  sarcoma  from  the  muscle-fibers  seemed  evident,  and  as  the  term  myosarcoma  is  definitely 
fi.xed  in  the  literature,  and,  furthermore,  since  it  clearly  indicates  to  the  physician  the  clinical 
picture,  we  have  thought  it  much  wiser  to  stick  to  this  word. 

t  Virchow:   Die  Krankhaften  Geschwiilste,  Bd.  iii,  S.  201. 

X  Chrobak:  Arch.  f.  Gynilk.,  1872,  Bd.  iv,  S.  549. 

§  Ritter:   Dissert.  Inaug.  Ueber  d.  Myosarkom  des  Uterus,  Berlin,  1887. 

II  Williams,  . J.  Wliifridge:  Contributions  to  the  Histology  and  Histogenesis  of  Sarcoma  of 
the  Uterus,  Am.  Jour,  of  Obstet.,  1894,  vol.  xxix,  No.  (i. 

^  Schreher:  "Ueber  d.  Complikation  von  Utenisinyoiii  init  .sckiuidiircr  sarkomatoser  Degen- 
eration," Diss.  Inaug.,  Jena  [Strassburg],  1894. 

**  Pick,  L.:  Zur  Histiogciiese  und  Classification  tier  ( iclnirMiutlcrsarcdnic,  .Vrcli.  f.  (iviiiik., 
189,"),  xlviii,  8.  24.  Arcli.  f.  (lyiuik.,  189."),  S.  :V.i.  Zur  Lelire  voin  .Myoma  sarcomatosum  und 
iiber  die  sogenannten  Undotlu'lioinc  dcr  Ocbiirmvitter,  .Vrcli.  f.  (lyniik.,  1S9.">.  xlix.  S.  1. 

ft  Gessiior:    N'cit's  Han(ll)iich  dcr  ( lyniikolniric.   1S99.  iii.  Zwcitc  Iliilftc,  S.  9.')7. 

tl  Wt'ir,  Wni.  II.:  Musc1c-<t11  Siircoriiata  dl"  (lie  I'tcriis,  .\iii.  .I.iur.  (if  (  )l.stct..  1901,  vol.  xliii, 
618. 

§§  Jacobi,  .Mary  I'utnain.  and  WOllstcin,  .Martha:    .\\u.  .loiir.  nf  <  »l)stct..  1902.  vol.  xlv.  p.  218. 

nil  Fehling:   Centralb.  f.  Cyn..  ISOS.  xxii,  S.  Ills. 

•[^Martin,  A.:    Ueber  Myoinc,  NCrh.  d.  dculsch.  ( k's.  f.  (lyii.,  ii.  S.  12.). 

169 


170  MVOMATA    OK    TIIK    ITERUS. 

In  oui'  scries,  which  now  cinhniccs  over  1400  cases.  17  sliowed  undouhtcd  sarco- 
mata of  the  uterus  occurring  in  or  associated  with  niyoniata.  In  17  other  cases 
suspicious  gross  or  histologic  pictures  were  present,  but  the  changes  in  these 
were  not  sufficient  to  warrant  a  positive  diagnosis  of  sarcoma.  Now,  since 
many  of  our  cases  were  not  examined  histologically  unless  they  jn-esented  sus- 
picious macr()scoj)ic  ])ictures,  and  again,  in  view  of  tlie  fact  that  it  would  be 
almost  ini])ossible  to  examine  every  portion  of  a  myomatous  uterus  histo- 
logically, without  doubt  some  cases  have  been  overlooked.  During  the  last 
decade  hysterectomies  and  myomectomies  for  myoma  have  become  much  more 
frecjuent,  and  careful  clinical  histories  and  pathologic  records  have  been  kept. 
We  feel  confident  that,  as  a  result  of  these  careful  studies,  in  the  next  few  years 
many  cases  of  sarcomata  developing  in  myomata  will  be  reported,  and  that  this 
malignant  change  will  l)e  found  to  be  relatively  connnon. 

The  Gross  Appearances  of  Myosarcomata, — Uterine  myomata  are  usually 
multiple.  Thus,  in  those  cases  in  which  a  sarcomatous  change  takes  place 
several  other  myomata  are  almost  invariably  present.  The  nodules  may  be 
subperitoneal,  interstitial,  or  submucous.  As  a  rule,  only  one  nodule  undergoes 
a  malignant  change,  but,  as  in  von  Kahlden'.s*  case,  sarcomatous  foci  may  occur 
simultaneously  in  several  myomata.  In  the  very  early  stages  the  macroscopic 
changes  may  be  totally  wanting  or,  as  has  been  pointed  out  by  Chrobak, 
they  may  be  so  slight  as  not  to  be  recognized.  This  was  clearly  shown  in 
San.  No.  1857  (Fig.  137,  p.  206 ) .  Here,  lying  to  the  side  of  the  cervix,  was  a  myoma 
several  centimeters  in  diameter.  Macroscopically  it  differed  in  no  way  from  the 
oi'dinary  myoma,  and  yet  on  histological  examination  the  transition  of  muscle- 
cells  into  sarcomatous  tissue  was  pei'fectly  evident.  Where  th(^  malignant  change 
is  present,  it  is  usually  readily  recognized.  The  ))inkish-white  tissue  with  the 
coarse  fibrous  arrangement  has  been  in  part  re])laced  by  a  yellowish-wliite,  homo- 
geneous tissue,  almost  totally  devoid  of  fibrous  elements,  and  l;)earing  a  striking 
resemblance  to  raw  \H)vk.  The  sarcomatous  is  usually  sharply  differentiated  from 
the  myomatous  tissue,  but  now  and  then  gradually  merges  into  it.  Sometimes 
the  sarcoma  presents  a  jjoious  ap])earance,  as  noted  in  Fig.  138  (p.  209)  and  Fig. 

131  (p.  193),  or  it  may  contain  large  and  small  cyst-like  spaces,  as  seen  in  Fig. 

132  (p.  197),  Fig.  133  (p.  198),  and  Fig.  140  (j).  213).  These  were  also  noted  in 
Menge's  case.  They  are  probably  dilated  lymph-spaces.  The  sarcomatous  tissue 
is  exceedingly  soft,  and  from  its  surface  a  considerable  amount  of  fluid  can  be 
sfjueezed.  As  exemplified  in  Case  8732  (p.  215),  the  growth  may  be  soft — so  soft 
that  it  rt^sembles  brain  tissue.  With  the  advance  of  the  sarcoma  hemorrhages 
take  place,  giving  the  cut  surface  a  i( ddish-brown,  mottled  ajijx'arance.  which 
after  a  time  is  i-eplaced  by  a  yellowish  or  yellowish-brown  color,  due  to  the  de- 
position of  blood-pigment.  In  a  short  time  the  central  portions  of  the  tumor 
undergo  coagulation  necrosis,  followed  by  li(|uefacti()n  (see  Fig.  138,  p.  209). 
Th(>  sarcomatous  changes  usually  connneiice  in  t  he  central  [joilions  of  the  myoma, 

*  \'(jii  Kahldcii:    Zicdor's  Hcitnigo  ziir  i)atli.  Aiiatoiiiic  uml  allu;.  Patliologie,  1.SS3.  xiv.  S.  174. 


MYOSARCOMA    OF   THE    UTERUS.  171 

but  occasionally  occur  in  the  periphery.  The  latter  seems  to  have  been  the 
case  in  Fig.  143  (p.  217),  in  which  the  renmants  of  a  myoma  are  entirely  sur- 
rounded by  sarcomatous  tissue.  With  the  advance  of  the  growth  secondary 
pure  sarcomatous  nodules  become  scattered  throughout  the  uterine  walls,  as 
is  well  seen  in  Fig.  140  (p.  213)  and  Fig.  143  (p.  217);  or  sarcomatous  polypi  may 
project  into  the  uterine  canal,  as  shown  in  Fig.  138  at  i.  (p.  209). 

In  Figs.  125  (p.  1S5)  and  126  (p.  186)  is  represented  a  most  unusual  secondary 
nodule  in  Path.  No.  7555.  The  uterus  was  small,  and  its  interstitial  myomatous 
nodule  showed  marked  hyaline  changes  and  also  sarcomatous  transformation 
of  muscle-fibers.  Attached  to  the  posterior  surface  of  the  utems  was  a  large, 
cockscomh-likc  secondary  growth,  which  on  histologic  examination  was  found 
to  consist  essentially  of  tissue  that  was  of  even  a  more  pronounced  sarcomatous 
type  than  that  of  the  primary  tumor. 

The  older  writers  claimed  that  myomata  that  underwc^nt  sarcomatous  de- 
generation were  almost  invariably  submucous.  Our  experience,  however, 
goes  to  show  that  the  malignant  change  may  equally  well  start  in  a  subperitoneal 
or  interstitial  myoma. 

The  following  table  gives  the  location  of  the  sarcomatous  growths  in  our 
cases : 

Interstitial:   Gyn.  Nos.  11944.  6724,  7040.  7474.  8610,  8732.8836.  S.  1879  (partly  submu- 
cous), Path.  No.  6421 9  cases 

Subperitoneal:   Gyn.  Nos.  6045,  7604.  9536,  12155 4      " 

Intraligamentary:   S.  1857 1  case 

Submucous:   Gyn.  Nos.  7313.  10376  (uterus  not  removed).  Path.  No.  7555 3  cases 

17  ca.ses 

Uterine  myomata  are  usually  at  first  interstitial  and  eventually  become 
either  submucous  or  subperitoneal.  In  former  years  when  few  abdominal 
operations  were  performed  naturalh'  only  the  sul)nuicous  sarcomatous  nodules 
were  recognized  clinically.  From  a  study  of  our  table  it  will  be  seen  that  over 
half  the  cases  were  interstitial,  and  that  the  inter.stitial  and  .subperitoneal  myo- 
mata undergoing  sarcomatous  changes  wei'e  far  in  excess  of  those  of  the  sub- 
mucous group.  In  only  three  out  of  oui'  se\-eiiteen  cases  wei'e  the  sarcomatous 
myomata  submucous.  Of  coiu'se,  at  a  later  date  .some  of  these  myomata  would 
have  undoubtedly  migrated  into  the  uterine  cavity  and  have  become  subnuicous. 

Case  6045  and  Case  9536  (Fig.  123,  ]).  ISl )  areexcellent  examjiles  of  sarcomata 
commencing  in  subperitoneal  myoinata;  I'ig.  1 3S  (p.  209)  shows  a  sarcoma  de- 
veloping in  an  intei'stitial  myoma.  In  the  latter  case  it  seems  more  ])robal)le 
that  the  growth  in  time  would  tend  to  extend  more  and  more  into  the  uterine 
cavit>'.  If  a  myosai'coma  projects  into  the  uterine  (•;uial,  it  usually  becomes 
lobulated  fi'oin  liie  I'apid  character  of  the  gi'owth.  ;ind  we  h;i\'e  the  ex])ulsion 
through  the  vagina  of  ;i  tumor  usually  su|)|)ose(l  to  be  a  submucous  myoma. 
The  original  growth  si  ill  coniinues.  but  after  a  short  time  further  portions  are 
expelle(|  in  a  similai'  manner. 


172  MYOMATA    OF   THE    UTERUS. 

Histologic  Appearances  of  Myosarcomata. — Sarcomata  developing  from 
myomata  are  divisible  into  two  varieties:  (1)  Sarcomata  developing  from  the 
connective  tissue  of  the  myomata;  (2)  sarcomata  dc^veloping  from  the  myomatous 
muscle. 

Of  course,  there  are  undoubted  cases  in  which  the  sarcoma  develops  in  part 
from  the  connective  tissue  and  in  part  from  the  transition  and  multiplication 
of  muscle-fibers.  Macroscopically  both  these  varieties  present  the  same  ap- 
pearance and  naturally  require  precisely  the  same  operative  interference. 

1.  Sarcomata  Developing  from  the  Connective  Tissue  of  Myomata. — Virchow 
was  one  of  the  first  to  describe  this  variety,  and  his  description  is  so  good  that 
we  cannot  do  better  than  quote  him  directly:  ''The  degeneration,  as  I  have 
traced  it,  is  as  follows.  At  certain  ])oints  the  intercellular  substance  commences 
to  grow,  the  cells  increase  through  division.  Thus  more  and  more  round  cells 
are  formed,  at  first  small,  later  larger  and  larger  and  with  bigger  nuclei.  Mean- 
while the  intercellular  substance  becomes  less  and  more  rarefied  and,  while 
the  stroma  increases,  the  muscle  disappears  entirely  in  many  places.  At  other 
points  it  still  persists  and  even  increases.  In  this  manner  the  trabecular  character 
of  the  growth  develops.  The  cells  grow;  many  of  them  become  angular  and 
develop  processes  and  their  nuclei  reach  the  size  of  epithelial  nuclei.  They  are, 
however,  usually  arranged  in  rows  or  groups.  With  this  increase  in  the  cellular 
elements  the  original  stroma  is  in  pari  or  entirely  replaced  by  the  new  growth. 
Such  portions  become  soft,  friable,  and  have  a  whitish  or  yellowish  appearance. 
Comparatively  large  blood-vessels  penetrate  the  softer  portions  and  give  rise 
to  hemorrhagic  infiltration.  In  this  way  a  portion  of  the  cyst-like  spaces  are 
produced." 

Every  one  nuist  agree  fully  with  Mrchow's  description.  In  our  own  Case 
7474  (Fig.  139,  p.  211)  we  have  an  excellent  example  of  the  development  of 
small  cells  into  larger  ones.  Side  by  side  we  have  crops  of  the  large  and  small 
cells,  while  in  the  immediate  neighborhood  all  intermediate  sizes  are  demonstrable. 
The  increase  in  the  cells  is  due,  as  A'irchow  pointed  out,  to  indirect  division. 
Sometimes  the  entire  normal  karyokinetic  cycle  can  be  traced  and  usually  many 
cells  with  atypical  forms  are  ])resent.  Now  and  then  direct  l)udding  of  nuclei  is  to 
be  seen.  Fig.  144  (p.  21S)  depicts  clearly  the  many  cell  forms  that  may  be  found. 
Here  we  have  small  and  large,  round  or  oval,  vesicular  nuclei;  large  and  small, 
deeply  staining  nuclei ;  large  and  irregular  and  partly  dividing  nuclei,  and  tre- 
mendous clumps  of  chromatin  scattered  throughout  large  ])laques  of  protoplasm, 
(iiant  cells  are  also  ])resent,  usually  with  their  nuclei  arranged  in  a  imilbei'ry- 
shaped  form.  Sarcomata  originating  from  the  connective-tissue  elements  of 
myomata  may  be  either  spindle-celled  or  round-celled.  These  sarcomata  may 
be  in  part  due  to  a  proliferation  of  the  endothelium  of  dilated. lymph-spaces,  as 
has  been  pointed  out  by  Chrobak  and  Menge.*  The  stroma  of  this  growth  at 
times  shows  distinct  myxomatous  degeneration.     As  the  sarcoma  iiicretises  in 

*  Menge:   Centralbl.  f.  Gynak.,  1895,  Bd.  xix,  S.  45.3. 


MYOSARCOMA    OF   THE    UTRRUS.  173 

size  the  central  portions  undergo  necrosis,  witli  or  without  fragmentation  of 
nuclei,  and  often  along  the  margin  of  the  necrosed  area  there  is  a  small-rouiul- 
celled  or  polymorphonuclear  infiltration. 

2.  Sarcomata  Developing  from  the  Muscular  Elements  of  Myomata* — Myo- 
sarcomata  are  usually  tlior.ght  to  be  derivatives  of  the  connective-tissue  portions 
of  myomata.  Nevei-theless,  recent  investigations  tend  to  show  that  a  fair  pro- 
portion are  due  to  a  direct  transformation  of  normal  muscle-fibers  into  malignant 
fibers.  As  far  back  as  1860,  however,  Virchow  when  describing  those  of  connective- 
tissue  origin  said:  ''The  muscle  disappears  entirely  in  many  places;  at  other 
])oint8  it  still  persists,  and  is  even  increased,"  thus  indicating  that  the  muscle 
might  take  part  in  the  process.  Von  Kahldenf  reported  a  case  in  which  he  was 
sure  he  was  able  to  trace  the  direct  transition  of  myomatous  muscle-cells  into 
sarcomatous  cells.  To  Williams  we  are  indebted  for  the  most  clear  and  con- 
vincing proof  that  the  muscle-fibers  are  actually  capable  of  becoming  malignant. 
Similar  and  confirmatory  evidence  has  been  furnished  by  L.  Pick,  Morpurgo,:{: 
Gessner,§  Veit,||  Gebhard,l[  Weir,  and  others. 

In  thirteen  of  our  seventeen  cases  (S.  1857,  S.  1879,  Gyn.  Nos.  6045,  6724, 
7313,  7604,  8836,  9536,  10376,  11944,  12155,  Path.  Nos.  6421  and  7555)  the  sar- 
coma was  apparently  the  result  of  a  transformation  of  the  myomatous  muscle- 
fibers,  and  in  one  further  case  (Gyn.  No.  8610)  the  sarcoma  seemed  also  to  have 
resulted  from  an  alteration  in  the  muscle-fibers.  But  the  proof  in  the  last  case, 
although  strongly  suggestive,  was  not  sufficient  to  enable  us  to  make  an  absolute 
statement. 

Of  the  remaining  cases,  Gyn.  No.  7474  (Fig.  139,  p.  211)  seemed  to  be  a  round- 
celled  sarcoma.  Gyn.  No.  7040  was  a  mixed-cell  growth  and  Gyn.  No.  8732 
wasaveryunusual  mixed-celled  sarcoma  (Fig.  144,  p.  218),  containing  areas  closely 
resembling  decidua,  and  others  strongly  suggestive  of  syncytium.  From  the 
above  it  will  be  seen  that  out  of  the  seventeen  cases,  in  thirteen  the  sarcoma  had 
resulted  aj)parently  from  an  alteration  in  the  muscle-fibers,  and  in  the  remaining 
cases  the  ])resumptive  evidence  was  in  favor  of  a  similar  origin. 

A  reference  to  Case  6045  (p.  223),  with  its  figures  (146,  147.  14S.  14<).  150, 

*  Mallory  has  recently  drawn  attention  to  the  fart  that  spccinicns  of  tliis  cliaractcr  iniisl  lie 
cut  in  small  pieces  and  hardcncMJ  within  a  few  ininntcs  after  removal,  otherwise  the  liner  details 
will  be  lost.  Xearly  all  of  our  cases  were  operated  u|)oii  ix'foic  his  article  appeared,  and  conse- 
quently his  technic  could  not  be  employed.  In  tiiis  connection  a  thorough  study  of  Mallory's 
exhaustive  and  painstaking  articles  cannot  fail  to  be  jjrohtable.  .Mallory,  F.  H.:  A  Contrilni- 
tion  to  the  Classification  of  Tumors,  Jour.  .Med.  Research,  vol.  xiii,  Jan.,  19()">.  Resvdts  of 
the  Application  of  Histological  .Methoils  to  the  Stvidy  of  Tumors,  Jour.  Kxjier.  .Med.,  vol.  \, 
No.  5,  Sept.  ;'),  1908. 

t  Von  Kahlden:   Ziegler's  i^eilriige  /.ur  path.  Analoniie  und  aU'j:.  I'aihologie,  ISiKi,  xiv,  !>.  171. 

}:  .Morjjurgo:  Ueber  sarkonialmlii-he  und  nialiy:ne  I  .eioinyonie.  /tschr.  f.  Heilkunde,  1895, 
It),  S.  157. 

§  Gessner;    XCilV  ll.indl.iicli  di'r  (  iynakologie,   IS'.l't,  iii,  Zweite  llaifte,  S.  957. 

II  Veit:  llandbuch  d.  CyiiakoloLMc.   1S1»7,  IM.  ii.  S.    191. 

«!r.el)hard:    \'cit 's  iiandiiurli  der  (  Ivnakologie,   1S<.)7,  ii.S.    III. 


174  MVO.MATA    OF    THE    UTKRUS. 

151,  152,  153,  154,  and  155).  will  give  the  reader  a  clear  idea  of  the  various 
transition  stages  of  the  myoma  into  sarcoma. 

In  order  to  follow  these  ohanges  satisfactorily  it  is  always  necessary  to  ob- 
tain sections  at  the  outer  edge  of  the  growth,  because  in  the  central  portion  all 
trace  of  the  myomatous  muscle  has  disappeared  and  its  i)lace  is  occupied  by 
spindle-celled  sarcoma.  In  Case  6045  the  change  had  been  a  very  gradual  one 
antl  many  distinct  foci  could  be  traced  near  the  border  of  the  growth,  indicating 
that  there  was  a  gen(>ral  tendency  for  the  myoma  to  become  malignant.  In 
Fig.  150  ()).  '227)  we  see  typical  myomatous  muscle-fibers.  A  short  distance 
further  on  are  nuclei  twice  the  size,  then  four  or  five  times  as  long,  correspond- 
ingly broad,  and  containing  a  slight  increase  in  chromatin;  and  finally  we  en- 
counter bunches  of  very  large  nuclei  containing  great  (juantities  of  chromatin. 
In  this  picture,  then,  we  have  all  gradations,  from  the  normal  to  the  unmistak- 
able sarcomatous  fib(>r.  Fig.  148  (p.  225),  taken  from  a  hyaline  area  at  some 
distance  from  the  unun  growth,  is  even  more  easily  followed,  inasmuch  as  here 
the  cells  are  further  apart.  Here  also  the  gradual  and  yet  steady  increase  in  the 
size  of  the  nuclei  is  easily  followed.  In  Fig.  149  (p.  226)  from  the  same  case, 
cross-sections  and  longitudinal  sections  of  muscle-bundles  are  still  clearly  visible. 
Nevertheless,  in  each  of  them  all  stages  in  the  transition,  from  the  slender, 
spindle-shaiM'd,  to  the  very  large  elongate  and  deeply  staining  nuclei,  can  be 
followed.  Figs.  151,  152,  153,  154  (p.  228),  from  the  same  case,  are  even  more 
convincing.  In  Fig.  151,  at  a  we  have  a  cross-section  of  a  muscle-bundle  with  the 
tips  of  muscle-fibers  still  pi-eserved,  and  yet  sufficient  changes  have  taken  place  in 
the  surrounding  muscle-fibers  to  render  a  diagnosis  of  sarcoma  certain.  Other 
portions  of  the  same  specimen  show  all  transition  forms.  The  cells  in  Figs.  152, 
153,  and  154  of  the  same  case  illustrate  admirably  the  relatively  huge  dimensions 
that  these  cells  may  attain,  and  also  show^  clearly  the  presence  of  large  numbers  of 
hvaline  droplets  in  the  giant  nuclei.  As  w^e  pass  toward  the  center  of  the  growth 
the  sarcoma  is  found  to  be  composed  of  a  sea  of  cells,  chiefly  spindle-shaped,  and 
usually  so  closely  packed  togeth(>r  that  the  cell  outlines  are  hard  to  differentiate. 
Traversing  the  sarcoma  are  large  and  small  blood-vessels  almost  totally  devoid 
of  stroma.  Case  9536  also  shows  clearly  the  gradual  transition  from  the  myoma- 
tous nmscle-fibers  into  the  sarcomatous  growth.  Fig.  124  (p.  182)  is  taken  from 
the  growth  seen  in  Fig.  123  (p.  bSl)  and  is  at  the  junction  of  the  sarcoma  with  the 
myoma.  The  left  portion  of  the  section  contains  nmscle-fibers  slightly  swollen 
but  otherwise  unaltered.  As  we  pass  to  the  right,  however,  the  nuck>i  increase 
rapidly  in  number,  are  more  spherical,  and  are  somewhat  enlarged.  Some  of 
them  also  contain  an  increased  amount  of  chromatin.  Near  the  right  border 
of  the  section  the  nuclei  have  become  clumped  together,  forming  giant-cells. 
The  tissue  immediately  beyond  this  was  that  of  a  typical  sarcomatous  growth. 
The  .subseciuent  degeneration  in  this  variety  of  sarcoma  is  similar  to  that  occur- 
ring in  those  arising  from  the  connective-tissue  ])ortions  of  myomata. 

Thus  we  have  sarcomata  developing  in  uterine  myomata.     These  nuiy  be  of 


MYOSARCOMA    OF   THK    UTERUS. 


175 


connect ivo-t issue  origin,  and  are  cither  si)in(lle-e('llc(l  or  round-celled.  We  also 
have  sarcomata  developing  from  the  nmseular  dements  of  the  myoma.  These 
are  invariably  spindle-celled.  Of  course,  it  is  (juite  possil)le  that  both  stroma 
and  muscle  may  take  part  sinmltaneously.  This  division  into  the  two  varieties 
is  of  purely  pathologic  interest,  as  it  can  be  determined  only  on  careful  histologic 
study.     It  is  of  no  particular  import  to  the  surgeon. 

In  San.  No.  1852.  included  among  the  adenomyoma  eases  ("  Adenomyoma 
of  the  Uterus,"  p.  225).  we  have  a  very  interesting 
example  of  adenocarcinoma  of  tlie  l)ody  of  the 
uterus  developing  in  part  from  a  preexisting 
adenomyoma.  Commencing  sarcoma  was  also 
present  in  the  body  of  the  uterus. 

A  careful  study  of  the  pathologic  deseri])tioii 
of  the  cases  certainly  suggests  that  in  many  in- 
stances hyaline  degeneration  has  been  the  fore- 
rminer  of  the  malignant  change.  The  muscle- 
fibers  scattered  throughout  the  hyaline  and 
partially  liquefied  material  have  a  much  more 
fa^'orable  opportunity  for  swelling  up  or  for  taking 
ujjon  themselves  increased  activity,  not  being 
closely  packed  together,  as  in  the  ordinary  myoma. 
The  more  we  study  these  tumors,  the  more 
strongl}^  we  become  impressed  with  the  apparenth' 
predisposing  tendency  to  sarcoma  created  by  the 
])iMmaiy  hyaline  change. 

Secondary  Growths  of  Myosarcomata. — As  has 
been  noted  in  the  foregoing  pages,  with  sar- 
comatous degeneration  of  myomata  there  is  a 
sinniltaneous  increase  in  the  size  of  the  myoma, 
and  secondary  sarcomatous  nodules  fi-e(|uently 
become  scattered  thi'ougiioul  1  he  uterine  walls.  If 
the  nodule  be  .subperitoneal,  we  shall  exj)ect  the 
.sircoma  to  soon  reach  the  outer  surface  of  the 
myoma,  and  to  then  engraft  itself  u])on  the  sui- 
roimding  ti.ssues,  as  in  Case 95.%  (Fig.  123,  j).  ISl). 
in  which  the  large  subperitoneal  tumor  has  become 
intimately  attached  to  the  rectum,  .\gain.  in  Case  7  17  I  there  was  a  laige  aica  of 
iieci'osis  on  t  he  anterior-  s\n'face  of  I  he  t  umor.  l'"inlny*  I'eporls  an  inlei-est  ing  case 
of  a  woman.  Hfly-eight  years  of  age,  who  had  had  an  abdominal  tuinoi'  foi-  (ifieen 
years.  This  had  recent I\-  increased  niateiially  in  size.  She  died  eight  days  after 
admission  with  signs  of  peiilonil  is.  .\i  aulopsy  a  tumor  the  size  of  a  child's 
head  was  tound  .attached  to  the  fundus.  The  u|)|ier  porli(»n  showed  a  breaking- 
*  I'iiiliiy:     Iniiis.  of  tin-  I'liili.  .S,,c.  of  Londoii.   lss;5.  vol.  \\\iv.  p.   177. 


Fin.   122. — .\   SARroM.\Tors  Nodule 
IX     .\     L.\.RGK     Pf.lvic     Blood- 

VKSSEL.      (Nat.  size.") 

Path.  No.  7903.  The  original 
growth  started  in  the  uterus.  It  was 
a  -sarcoma  that  had  apparently  de- 
veloped from  a  myoma.  Dr.  Hunner. 
when  removing  the  uterus,  felt 
one  of  the  bloo<l-ves.«els  to  be  firmer 
than  u.suul,  and  on  further  dissection 
drew  this  ca-st  of  sarcomatous  tissue 
from  the  ve.-isel  lumen,  a  represents 
the  main  ve.s.sel:  h,  l>' ,  W .  are  secondar.v 
branches.  The  sarcoma  had  grown 
directly  into  the  vein. 


176  MYOMATA    OF   THE    UTERUS. 

down.  The  lower  portion  had  a  firm  consistence.  The  tumor  proved  to  be  a 
spindle-celled  sarcoma.  In  this  case  the  growth  had  become  adherent  to  and 
had  grown  into  the  bladder,  where  it  formed  a  fungating  mass.  Secondary 
sarcomatous  nodules  were  found  in  the  skin,  lungs,  and  heart  muscle.  Ritter* 
reported  an  instance  of  myosarcoma  with  subsequent  supravaginal  hysterec- 
tomy. The  patient  died  six  weeks  after  from  a  recurrent  growth.  In  this  case 
metastases  had  taken  place  into  the  lymph-glands  at  the  pelvic  brim.  These 
glands  broke  down  during  enucleation  and  were  found  to  contain  brain-like 
material.  In  this  case  so  malignant  was  the  growth  that  within  six  weeks 
after  the  ojieration  perforation  of  the  anterior  abdominal  wall  had  taken  place. 
Schreherf  points  out  that  metastases  in  otherwise  operable  cases  are  rare.  In 
the  late  stages  of  the  growth  he  mentions  metastases  in  the  liver,  lungs,  pericar- 
dium, omentum,  heai't  muscle,  and  vertebra^.  What  we  have  most  to  fear  is 
the  lightning  rapidity  with  which  the  growth  extends  to  the  surrounding  pelvic 
structures  rather  than  the  danger  of  metastases. 

In  our  cases  coming  to  autopsy  three  showed  metastases.  In  Case  7313  (p.  195) 
in  which  a  necrotic  submucous  myoma  and  a  subperitoneal  myoma  were  present, 
a  secondary  nodule  developed  in  the  broad  ligament,  and  later,  as  will  be  seen 
from  Dr.  Osier's  letter,  the  patient  evidently  had  metastases  in  the  glands  of 
the  neck,  in  the  lungs,  and  in  the  pleura^. 

The  growth  in  Gyn.  No.  12,155  (p.  200)  was  exceedingly  rapid,  as  within  a 
few  months  after  operation  a  large  secondary  tumor  was  found  in  the  right  upper 
abdominal  cjuadrant.  At  autopsy  this  nodule  was  found  to  be  in  the  liver. 
There  were  also  general  abdominal  metastases,  and  likewise  numerous  skin 
metastases,  which  were  readily  recognized  clinically. 

The  secondary  growths  in  Gyn.  No.  7604  (p.  220)  were  particularly  interest- 
ing, sarcomatous  nodules  being  found  in  the  chorda'  tendinea^  of  the  tricuspid 
valves  as  well  as  in  the  lungs. 

Some  of  the  sarcomatous  growths  show  a  decided  tendency  to  remain  local, 
as  noted  in  Path.  No.  6421.  In  this  case  two  years  after  the  supravaginal 
amputation  of  a  myomatous  uterus — the  sarcoma  being  at  the  time  com- 
pletely overlooked — there  was  a  local  return  in  the  cervical  stump,  and  at  the 
second  operation  no  metastases  were  apparent  (Fig.  130,  p.  191,  and  Fig.  131, 
p.  193). 

Condition  of  the  Uterine  Mucosa  in  Cases  of  Myosarcoma  of  the  Uterus. — 
In  very  few  of  the  cases  reported  has  any  attention  been  paid  to  a  description 
of  the  mucosa.  In  those  cases  in  which  the  interstitial  nodules  gradually  become 
submucous,  as  reported  by  Pick,  the  overlying  mucosa  becomes  atrophic; 
the  glands  are  pushed  aside  or  are  obliterated,  and  the  nodule  soon  lies  directly 
beneath  the  surface  ei)ithelium.     This  soon  yields,  and  eventually  the  submu- 

*  Hitter:    Dissert.  Inaug.,  Leber  d.  Myosarkom  des  Uterus,  Berlin,  1887. 
t  Schreher:   Ueber  d.  Complikation  von  Uterusinyoin  niit  sekuiidiirer,  sarkoniatoser  Degen- 
eration, Inaug.  Diss.,  Jena  [Strassburg],  1894. 


MYOSARCOMA    OF   THE    UTERUS.  177 

cous  myoma  over  its  most  prominent  pc^rtion  is  not  only  devoid  of  a  covering  of 
mucosa,  but  shows  breaking-doA^Ti  of  its  superficial  portions. 

In  thirteen  of  our  seventeen  cases  wc  have  definite  data  as  to  the  condition 
of  the  uterine  mucosa.  In  Gyn.  No.  7313  the  mucosa  here  and  there  showed  focal 
endometritis,  hut  was  on  the  whole  normal.  Projecting  into  the  uterine  cavity, 
in  Civn.  Xos.  7474  and  12,155,  were  pohq)i.  In  a  few  cases  minor  changes,  such 
as  dilatation  of  the  veins  in  the  mucosa,  dilatation  of  the  lymph-channels,  or 
dilatation  of  a  few  glands,  were  detected.  In  ten  out  of  thirteen  cases  the  mucosa 
was,  however,  practically  normal.*  This  is  exactly  what  one  might  expect 
when  the  tubes  and  ovaries  are  normal  and  when  a  sarcoma  is  either  interstitial 
or  subperitoneal.  When  the  growth  becomes  sul)mucous  and  sloughs,  the 
inflammatory  process  naturally  extends  to  the  surrounding  mucosa. 

Condition  of  the  Tubes  and  Ovaries. — The  appendages  seem  to  be  little  affected 
by  the  development  of  the  sarcomatous  growth.  In  fourteen  out  of  our  seven- 
teen cases  we  have  definite  data  as  to  the  condition  of  the  appendages.  In 
Case  7313  the  right  tube  was  the  seat  of  a  subacute  salpingitis  and  there  was 
pelvic  peritonitis.  The  left  tube  was  normal.  In  this  case  a  slight  focal  endo- 
metritis existed.  The  outer  end  of  the  right  tube  in  Case  6045  had  become 
lost  on  the  surface  of  the  tumor,  while  the  ovary  was  adherent  at  its  outer  pole. 

In  Gyn.  Nos.  7604,  8610,  and  8836  adhesions  were  also  noted;  in  the  remain- 
ing nine  the' tubes  and  ovaries  were  perfectly  normal. 

On  the  whole,  we  can  be  reasonably  certain  that  the  growth  exercises  little 
influence  on  the  appendages.  Of  course,  if  pelvic  adhesions  have  existed,  wc 
usually  expect  the  tubes  and  ovaries  to  be  implicated  in  this  process. 

Clinical  History  in  Cases  of  Myosarcomata  of  the  Uterus. — These  patients  usu- 
ally come  with  a  definite  history  of  uterine  myomata  of  several  years'  standing. 
Gessner  and  Weir  both  report  cases  in  which  a  myoma  had  been  detected  two 
years  previously;  Ritter  and  Weir  o!)served  instances  in  which  the  myoma 
had  been  recognized  at  least  ten  years  before  operation.  Finlay's  })atient  had 
had  a  distinct  abdominal  tumor  for  fifteen  years,  and  in  Langerhans'  patient,  who 
was  sixty  years  of  age,  the  tumor  had  been  demonstrable  for  twenty  years. 
In  Case  7212  the  myoma  was  detected  four  years  before  admission,  and  in 
Case  7474  a  period  of  twelve  years  had  elapsed  from  the  time  the  myoma  was 
first  recognized  until  operation.  In  Cast^  9536  the  growth  was  detected  only 
six  months  before  operation.  Here  the  tumor  was  posterior  to  the  uterus, 
was  situated  low  down  in  the  pelvis,  and  had  evidently  escaped  recognition  for 
a  much  longer  period.  Nearly  all  of  th(>  pati(>nts  giv(>  a  history  of  a  slow  develop- 
ment of  the  tumor  for  several  years,  with  a  marked  increase  in  growth  during 
the  last  few  months. 

*  Atropl)y  of  the  mucosa  is  iiiorely  a  rclati\c  tcriii.      W'licrc  tlic  surface  area  is  four  times  as 
great  as  normal,  owing  to  the  presence  of  a  myoma,  a  mucosa  ()iic-(|uartrr  i)\'  tlic  normal  thickness, 
although  apparently  atrophic,  is  in  reality  normal. 
12 


178  MVOMATA    OF    THK    ITKHUS. 

Age. — -As  seen  from  the  aooonipanyiii^  table,  the  highest  incidence  in  our 
cases  was  between  forty  and  fifty  }'ears  of  age: 

Gyn.    No.    6,724 age  27  San.    No.     1,857 age  46 

Gyn.   No     8,610 "    39  Gyn.    No.     9,536 "    48 

San.    No.    1,879 "    41  Gyn.   No.     8,836 "    48 

Path.  No.  6,421 "  42      Gyn.  No.  12,155 "  48 

Gyn.  No.  7,604 "  44      Path.  No.  7,.355 "  50 

Gvn.  No.  10,376* "  45      Gyn.  No.  I'^Jf^  ]    "  50 

Gyn.  No.  7,313 "  45      Gyn.  No.  7,474 "  52 

Gyn.  No.  8,732 "  46      Gyn.  No.  6,045 "  56 

Gyn.  No.  11.944 "  46 

thus  indicating  clearly  that  this  malignant  degeneration  is  most  fre(|uent  at  the 
age  at  which  carcinoma  also  is  prone  to  develoj). 

We  ha\'e  seen  that  sarcomata  may  develop  in  sul)])erit()neal,  interstitial,  or 
submucous  niyoniata.  H(>nce  the  clinical  picture  will  vary  according  to  the 
location  of  the  growth.  Where  the  growth  is  subperitoneal,  there  will  be  a 
rai)id  increase  in  size  of  the  tumor,  with  or  without  pressure  symptoms,  according 
as  the  growth  becomes  jammed  in  the  pelvis  or  not,  and  according  as  it  does  or 
does  not  extend  to  the  rectum  (see  Case  {)o'M),  p.  ISO).  Such  cases  usually  come  to 
0])eration  Ix'foi-e  the  disease  advances  further:  otherwise  the  growth  may  extend 
to  the  bladder,  if  that  viscus  has  been  drawn  u))\var(l  on  the  surface  of  the  tumor, 
and  in  a  short  time  we  shall  have  a  growth  projecting  into  the  bladder,  as  was 
noted  in  P'inlay's  case.  The  subperitoneal  tumor  itself  will  rarely  cause  uterine 
hemorrhage,  and,  if  a  bloody  vaginal  discharge  is  present,  it  will  ]3e  due  to  the 
existence  of  intei'stitial  or  subnuicous  myomata  in  the  same  uterus.  AVhere 
the  sarcomatous  myoma  is  interstitial,  there  may  be  a  general  enlargement  of 
the  uterus  with  extension  of  a  portion  of  the  growth  toward  the  peritoneal 
surface  or,  as  is  more  frequent,  toward  the  uterine  cavity.  When  the  growth 
enci'oachcs  on  the  utei'ine  cavity,  the  patient  will  have  hemorrhages.  This 
portion  of  the  gi-owth  is  forced  more  and  more  into  the  cavity  of  the  uterus, 
becomes  pedunculated,  and  then  often  undergoes  partial  necrosis.  The  hemor- 
rhages subsequently  increase,  and  in  the  interim  there  is  a  foul-smelling  watery 
discharge  due  to  disintegration  of  the  sloughing  growth.  The  intra-uterine  growth 
is  after  a  time  expelled,  and  the  patient,  who  has  become  very  anemic  and 
sallow  as  a  result  of  continual  loss  of  blood,  ra))idly  improves  for  a  time.  After 
a  \ai'iablc  ])eri()d  other  poi'tions  of  the  growth  become  subimicous  and  in  turn 
are  exi)elled  per  vaginam.  Hence  arose  the  term, '"  recurrent  fibroids."  Gessner 
mentions  well-known  cases  reported  by  Hutchinson,  Callender,  Paget,  and 
West,  and  fjuite  recently  many  similar  cases  have  been  published.  In  Case  7313 
(p.  195)  a  necrotic  submucous  n(»dul(' was  expelled  two  weeks  before  the  patient's 

*  The  tumor  in  tliis  ca.sc  was  a  subnuicous  sloughing  niyonui.  It  is  just  in  this  class  of  cases 
that  the  pathologist  finds  the  greatest  difhculty  in  differentiating  between  simple  disintegration 
of  the  myoma  and  sarcomatous  transformation.  The  changes  in  this  case  were  so  prono\inced 
that  from  the  histologic  picture  we  were  forced  to  classify  it  among  the  sarcomata. 


MYOSARCOMA    OF    THK    UTP^RUS.  179 

admission,  and  others  would  doubtless  have  followed  had  the  uterus  not  been 
removed.  Case  o4<)()  (p.  252)  is  a  typical  example  of  a  "recurrent  fibroid." 
The  patient  was  forty  years  of  age.  For  three  months  there  had  been  frequent 
hemorrhages  and  a  large,  sloughing,  cauliflower-shaped  myoma,  10  cm.  in  diame- 
ter, filled  the  vagina.  This  was  removed  and  the  uterus  was  packed  with  gauze. 
Two  months  later  a  similar  nodule  was  expelled  into  the  vagina,  and  for  another 
tw^o  months  there  was  perfect  relief.  Three  months  after  removal  of  the  second 
nodule,  a  third  pedunculated  myoma,  9  cm.  in  diameter,  was  removed  per 
vaginam.  At  the  end  of  a  year  this  patient  was  perfectly  well.  From  these 
cases  it  is  evident  that  some  of  the  "recurrent  fibroids"  are  sarcomatous  myo- 
mata,  others  are  simple  and  rapidly  growing  myomata.  It  is  often  exceedingly 
difficult,  and  in  fact  impossible,  to  determine  whether  these  submucous  growths 
are  sarcomatous  or  simply  edematous  and  necrotic  myomata.  We  found  no 
absolute  proof  in  our  case  of  "recurrent  fibroid"  that  it  was  malignant,  and 
clinically  the  patient  remained  well.  Gessner  says  that  Simpson  removed 
seven  successive  growths  through  the  vagina,  and  that  it  was  onh^n  the  seventh 
that  he  was  able  to  detect  sarcoma.  Of  course,  if  such  a  nodule  as  that  seen  in 
Fig.  138  (p.  209)  were  to  be  expelled  from  the  cervix,  the  diagnosis  would  be  clear. 
This  nodule,  however,  is  not  the  primary  growth,  but  a  secondary  one  from 
the  sarcomatous  portion  of  the  large  myoma. 

Pregnancy  may  occur  when  myosarcoma  exists.  Schreher  reports  a  case  in 
which  the  growth  was  situated  laterally,  suggesting  an  intraligamentary  cyst, 
and  in  the  uterus  was  a  four-months'  fetus. 

Color. — In  the  seventeen  cases  examined  by  us,  fifteen  of  the  patients  were 
white  and  two  colored. 

From  the  foregoing  it  is  seen  that  sarcomatous  myomata  present  few,  if 
any,  distinct  clinical  features.  Myomata  which  have  incn^ased  slowly  for 
years  often  take  on  a  rapid  development  without  becoming  malignant,  and  (^vcn 
when  "ivcurrent  fibroids"  are  present,  a  good  many  arc  simply  necrotic  myo- 
mata showing  no  malignant  changes.  Only  in  rare  instances  will  it  be  possible 
to  obtain  definite  evidences  of  sarcoma  from  extruded  subnnicous  tumors.  As 
seen  from  a  study  of  our  cases,  in  some  instances  sarcoma  was  not  for  a  moment 
suspected  until  the  uterus  had  been  I'emoved  to  the  laboratory,  and  even  then 
the  gi'owth  was  occasionally  overlooked.  In  those  cases  in  which  the  ojH'ration 
is  not  perfoi'ined,  dc.'il  h  iiiny  be  due  to  \\\r  coiilinuous  hemorrhage  j)roduciiig 
exhaustion,  but  occasionall\'  to  ^\•ide-sj)read  metastases. 

Treatment.  The  only  hope  of  sa\'ing  these  patients'  li\-es  lies  in  a  complete 
remo\'al  of  the  uterus.  In  nearly  all  of  the  cases  reported  in  the  lilei'ature.  and 
in  nearly  all  of  our  own,  su])i'a\'aginal  liyslereeioiny  was  jxTlorined,  the  o])eralor 
not  for  a  moment  hax'ing  suspected  sarcoma  e\'en  alter  the  abdomen  was  opened. 
In  every  case  in  which  sarcoma  is  susjx'cted  the  entire  oi'gan  must  be  i-enio\-ed, 
and  also  as  nnich  as  possible  of  t  he  jtarainet  rial  tissue.  Considering  the  mnnber 
of  cases  showing  sarcomatous  t  raiisfoi-niat  ion  of  myomata,  and  the  possibility 


180  :my()Mata  of  the  uterus. 

that  carcinoma  may  coexist  in  a  myomatous  uterus,  we  strongly  advise  that  in 
every  case  in  which  a  supravaginal  hysterectomy  is  deemed  preferable,  the  uterus 
be  opened  immediately  after  removal,  so  that  if  by  chance  a  malignant  growth 
be  present,  the  cervix  can  be  removed  without  delay.* 

No  better  example  of  the  necessity  of  carefully  examining  all  myomata  at 
once  could  be  foimd  than  in  Path.  No.  6421  (p.  190).  In  this  case  about  two 
years  after  a  supravagintU  hysterectomy,  the  patient  had  definite  signs  of  intra- 
abdominal hemorrhage.  At  operation  a  larg(>  sarcoma  was  found  developing 
from  the  cervical  stump.  Its  complete  removal  was  impossible.  On  examination 
of  the  original  tumor,  sarcoma  was  readily  recognized,  even  macroscopically. 
It  had  been  overlooked  in  the  laboratory. 

For  the  various  stej^s  in  a  com{)lete  a])dominal  hysterectomy  sec  page  588. 
^^^lere  the  growth  has  not  been  entirely  removed,  operation  evidently  hastens 
the  end.  In  Ritter's  case  thirty  days  after  supravaginal  hysterectomy  a  return 
of  the  growth  was  noted,  and  six  weeks  after  operation  the  patient  died,  the 
secondary  tumor  at  the  cervical  stump  having  reached  a  diameter  of  20  cm. 
The  growth  had  perforated  the  abdominal  wall.  In  Case  7212  a  movable  mass, 
the  size  of  a  walnut,  was  detected  at  the  cervical  stump  tAventy-six  days  after 
operation,  and  the  patient  died  less  than  thr(>e  months  from  the  date  of  the 
hysterectomy. 

In  Case  12,155  a  few  months  after  operation  a  large  metastatic  nodule  de- 
veloped in  the  liver,  and  the  patient  soon  died  of  wide-spread  disseminated 
abdominal  metastases. 

It  seems  to  us  probable  that,  when  the  supravaginal  hysterectomy  is  done, 
the  sarcomatous  growth  is  transplanted  in  various  directions  by  the  knife, 
and  that  it  commences  to  grow  with  increased  vigor.  As  will  be  seen  from  our 
cases,  the  immediate  results  following  hysterectomy  for  sarcoma  are  not  very 
gratifying.  In  all  cases  of  myosarcoma  there  seems  to  be  a  great  danger  of 
infection,  and  if  the  utmost  care  be  not  exercised,  a  local  or  general  peritonitis 
will  develop  from  the  necrotic  and  frequently  sloughing  sarcomatous  growth. 

Detailed  Report  of  Cases  in  which  Myomata  Became  Sarcomatous  or  were 
Associated  with  Sarcoma  of  the  Uterus. 

This  subject  is  of  such  practical  importance  tliat  each  of  our  cases  is  given 
in  detail. 

Gyn.  No.  9536.     Path.  No.  5730. 

Small  i  11  t  e  r  s  t  i  t  i  a  1  u  t  e  r  i  11  e  m  y  o  m  a  t  a  ;  large  sub- 
peritoneal my  0  111  a  densely  adherent  an  d  undergoing 
sarcomatous  transformation  (Figs.  123  and  124); 
normal    appendages. 

*  Cullen,  Thomas  S.:  Sarcomatous  Transformation  of  Myomata,  Jour.  Am.  Med.  Assoc, 
Oct.  2-1,  1903.  Immediate  Examination  of  Uterine  Mucosa  and  Myomatous  Nodules  after 
Hysterectomy,  to  Exclude  Malignant  Disease,  Jour.  Am.  Med.  Assoc,   March  10,  1906. 


MYOSARCOMA    OF   THE    UTERUS. 


181 


E.  C  ,  white,  marnod,  agcnl  f()rty-oio;ht.  Admitted  A))ril  7,  1902,  complaining 
of  pain  in  the  lower  abdomen.  Her  family  and  past  history  are  negative.  Her 
menses  commenced  at  fifteen,  were  regular,  lasting  four  days.  The  flow  was 
moderate  and  unaccompanied  by  pain.  There  has  been  a  slight  leukorrhea. 
She  has  been  married  thirty-two  years  and  has  had  three  children,  the  eldest 
thirty,  the  youngest  twenty-four. 

Six  months  ago  the  patient  began  to  suffer  from  pain  in  the  lower  abdomen, 
back,  and  rectum,  and  shortly  afterward  noticed  a  tumor.     There  was  increased 

frequency  of  micturition,  but  no 
other  symptoms.  On  admission 
the  geneial  condition  was  fair; 


Fig.  123. — Sarcomatocs  Transkormatio.n  of  a  Suupkritonkai,  Mvom<\.  with  Dkn.sk  .\nnKsioNs  to  the  Rectum 

AND  Piii.vic  Walls. 
Path.  No.  5730.  The  drawing  rei)re.sents  the  appearances  as  found  at  operation.  The  uterus  is  somewhat 
enlarged.  Situatetl  in  its  anterior  wall  is  an  interstitial  myoma;  in  the  posterior  wall  a  .smaller  one.  Attached  to 
the  posterior  surface  of  the  uterus  at  h  is  a  large  subperitoneal  myonui.  This  fills  the  entire  pelvis  and  extends 
aliovc  the  pelvic  Ijrim.  The  outlying  portions  (a)  itrescnt  the  typical  myomatous  appearance,  l>ut  the  entire 
central  jjortion  is  broken  down.  At  c  the  growth  is  iiitimatcl\  lilcndcd  witli  the  rectum.  From  tiie  text  it  will 
be  ijeen  that  the  disintegration  of  the  tumor  was  due  to  sarcom;itinLs   iruiisfoniialion  of  the  iiiMima. 

llic  tciii|icraliiiv  was  ii()nii;il.     Tliciv  was  :i  hard  mass  lilling  the  lower  altdtniieii 
and  exteiidiiiii;  to  within  ;i  ciii.  of  the  uinbiliciis. 

r)|)e]-atioii.  The  iitei'iis  was  situated  ;iiit  ei'ioiiy  and  abox'e  the  tumor,  which 
hlled  the  ])el\-is  and  w.as  densely  adherent.  (  )n  account  of  the  adhesions  the 
uterus  and  tumor  w(av  liisceleiL  Ndt  all  of  I  he  t  uinoi-  could  he  u'ol  I  en  fi-om  t  he 
jH'lvic  llooi-  and  many  bleeding  ])()iiits  were  left.  Two  gau/e  di'ains  were  carried 
down  to  the  pelvic  lloor.  The  i)atieiit  was  in  good  condition  on  leaving  the 
table. 


182 


MYOMATA    OF   THE    UTERUS. 


h 


bj. 


Diirinp;  the  next  clay  she  had  severe  pain  in  the  h'ft  lower  abdomen.  Her  pulse 
was  110,  the  teniju'rature  101.5°.  There  were  vomiting  and  distention.  The 
bowels  iiio\-e(l  on  tlic  second  day  and  all  the  paeks  were  removed.     She  developed 

signs  of  intestinal  obstruetion,  and 
on  the  fourth  day,  the  day  of  her 
death,    her    temperature    reached 
105°.     No  autopsy  was  obtained. 
^4       I      \      y     ^  >^'7^^<*^^-^';  Path.  No.  5730.     The  specimen 

consists  of  the  ut(M'us  with  a  tumor 
springing  from  its  posterior  sur- 
face, and  also  of  the  appendages. 
The  uterus  has  been  amputated 
through  the  cervix.  It  is  6  cm.  in 
length  and  6  cm.  in  its  antero- 
j)osterior  diameter.  This  increase 
in  thickness  is  due  to  two  myo- 
matous nodules,  one  situated  in  the 
])()sterior,  the  other  in  the  anterior, 
wall.  Attached  to  the  left  side  of 
the  uterus  near  the  cervix  is  a 
tumor  mass.  a])proximately  15  cm. 
in  its  longest  diameter  (Fig.  123). 
This  nodule  ])i'esents  a  distinctly 
myomatous  appearance,  and  over  a 
wid(>  area  is  covered  with  dense 
adhesions.  On  section  fully  one- 
half  of  the  tumor  ])resents  a  nodu- 
lar myomatous  picture.  The  re- 
mainder is  softer  in  character, 
slightly  homogeneous,  and  suggests 
sarcoma.  The  centi'al  ])ortion  of 
this  suspicious  area  has  midergone 
degeneration.  Here  the  tissue  is 
hemorrhagic  and  very  friable  and 
in  this  ai'ea  is  an  irregular  cavity, 
5  by  4  cm.,  which  has  a  smooth 
inner  surface.  The  uterine  cavity 
is  of  normal  length  and  its  mucosa 
appears  to  be  unaltered.  The  ap- 
pendages on  both  sides  are  normal. 
Histologic  Examination. — Sections  from  the  uterine  cavity  show  that  the 
mucosa  is  practically  normal.  The  more  solid  portion  of  the  larg(>  nodule  spring- 
ing from  the  posterior  wall  on  the  left  side  consists  of  typical  myomatous  tissue. 


^i  \ 


I*  ' 


Fig.  124. — Transition  ok  Myomatous  ixto  Sarcomatoi's 
Tissue.  (X  180  diam.) 
Path.  No.  5730.  The  section  is  taken  from  Fig.  123, 
where  the  myoma  is  undergoing  "softening,"'  or,  in  other 
words,  sarcomatous  transformation.  .\t  a  the  myomatous 
tissue  with  some  hyaline  degeneration  is  seen.  At  b  the 
nuclei,  although  still  of  the  same  shape,  are  arranging 
themselves  in  a  long  row,  each  nucleus  overlapijing  its 
neighbor.  At  c  the  tissue  has  already  become  sarcomatous. 
There  is  an  increased  amount  of  chromatin  at  d,  and  at  e,  e, 
are  large,  mulberry-shaped  giant-cells.  The  nuclei  com- 
posing these  giant-cells  are  similar  in  size  to  the  isolated 
ones,  f  is  a  blood-vessel;  g,  one  of  the  irregular  clear 
spaces  scattered  throughout  the  tissue.  This  field  is  given 
to  show  the  transition  of  the  myomatous  into  sarcomatous 
tissue.  Sections  near  the  center  of  this  tumor  are  the  most 
typical  examples  of  a  mixed-cell  sarcoma  that  we  have  ever 
seen  developing  from  a  myoma. 


MYOSARCOMA    OF   THE    UTHKUS.  183 

The  softer  porliun  presents  an  entirely  different  picture.  At  the  junction  of  the 
myomatous  tissue  with  the  softer  growth  the  niusch'-fil)er8  are  increased  in  size 
(Fig.  124) .  Their  nuclei  are  also  larger  and  irregular  and  stain  more  dec^ply.  The 
softer  growth  consists  of  spindle-shaped  cells  closely  packed  together,  and 
scattered  throughout  this  growth  are  many  plaques  of  protoplasm  containing 
from  two  to  ten  or  more  large,  deeply  staining  nuclei.  These  giant-cells  are 
everywhere  in  evidence.  The  l)lood-vessels  in  the  areas  above  described  have 
very  thin  walls  and  lie  in  direct  contact  with  the  tumor  cells.  A  considerable 
degree  of  necrosis  has  taken  place,  large  areas  having  undergone  complete 
coagulation  changes.  In  such  areas  the  blood-vessels  remain  intact.  In  some 
of  the  large  veins  thrombosis  has  taken  place,  and  cells  of  the  new  growth  have 
wandered  in  and  arc  replacing  the  blood. 

We  are  dealing  with  a  myoma  showing  undoubted  transformation  into  sar- 
coma. In  other  places  we  have  a  large  myomatous  nodule  presenting  the  typical 
appearance  in  many  places,  and  scattered  throughout  it  are  softened  areas  which 
are  clearly  sarcomatous.  Moreover,  the  histologic  examination  shows  that  there 
is  direct  transition  from  the  myoma  into  sarcoma  cells,  all  gradations  being  found. 

Gyn.  No.  10376.     Path.  No.  6596. 

S  1  o  u  g  h  i  n  g  sub  ni  n  c  o  u  s  m  y  0  m  a  u  n  d  e  r  g  o  i  n  g  s  a  r  c  o  in  a  t  - 
o  u  s    t  r  a  n  s  f  o  r  m  a  t  i  o  n  . 

M.  S.,  white,  married,  aged  forty-hve.  Admitted  April  1;  discharged  April 
17,  1903.  The  patient  complains  of  a  })elvic  tumor.  She  has  always  been 
healthy  until  the  present  illness.  The  menstrual  history  for  five  years  was  pain- 
ful, but  after  that  she  had  no  discomfort.  The  flow  has  been  normal  up  to  the 
present  illness.  The  patient  has  been  married  twentj'-eight  years,  has  had 
eight  children,  the  eldest  twenty-seven,  the  youngest  five  years  old.  For  five 
years  she  has  had  very  severe  backache  and  last  year  rather  profuse  hemorrhage 
during  the  menses,  and  occasionally  .some  bleeding  betwcM'u  titnes.  She  has  lost 
a  great  deal  of  blood,  and  for  the  ])ast  two  months  has  been  in  bed  practically  all 
the  time.  I  ler  si  rengt  li  has  greatly  diiiiinished,  her  appetite  is  ])oor,  and  she 
is  much  constipated. 

The  ])atient  is  lai'ge  and  fat.  The  heart  is  dihiled  and  extends  fail  her  to  the 
left  than  \isual;  there  is  a  systolic  munnur  at  the  apex,  which  is  transmitted  to 
the  axilla:  thei-e  is  also  a  systolic  nnu'nnu'  in  the  |)uhnonarv  area  and  a  double 
murnnu"  in  the  aoi'tic  area.  The  pulse  is  typical  of  aortic  insuliiciency.  and  thei'e 
is  j)robably  both  mitral  and  aortic  disease,  llei'  hemoglobin  is  30  pel"  cent. 
The  vagina  is  lille(l  with  a  dull  red  mass  al)oul  IL*  em.  in  diameter.  There  is  a 
very  |)rofuse,  fi)ul-snieHing  discharge.  The  |iel\ic  landmarks  are  diliicull  to 
outline,  but  one  can  feel  the  edge  of  the  cel'xix  surrounding  the  pedicle  o|'  ihe 
growth. 

( )|)eration.  The  tumor  was  renioNcd  in  fragments  without  much  hemorrhage. 
It  apparently  had  a  broad  peilicle.  which  was  thoroughly  curetteil.      l-"our  pieces 


184  MYOMATA   OF   THE   UTERUS. 

of  gauze  were  packed  into  the  uterine  cavity.  The  highest  temperature  after 
operation  was  101.8°;  it  droi)ped  to  normal  by  the  fifth  day.  The  convalescence 
was  uninterrupted.  At  the  time  of  her  discharge  the  uterus  was  considerably 
enlarged  and  nodular.     The  symptoms,  however,  had  been  completely  relieved. 

Path.  No.  6596.  The  specimen  consists  of  fragments  of  a  foul-smelling, 
friable  tissue,  amounting  in  all  to  about  700  c.c;  the  largest  piece  measured 
7x4x3  cm. 

On  histologic  examination  many  sections  are  found  to  consist  almost  entirely 
of  blood-clots  rich  in  fibrin  and  containing  quantities  of  polymorphonuclear  leu- 
kocytes. In  many  places  what  at  first  sight  appears  to  be  blood  consists  of 
numerous  very  much  dilated  blood-vessels.  Further  sections  show  areas  of 
myomatous  tissue  \-ery  rich  in  cell  elements  and  here  and  there  showing  hyaline 
degeneration.  The  cells  for  the  most  part  are  fusiform  in  shape  with  moderately 
dee])ly  staining  nuclei.  Others  have  more  or  less  oval  nuclei.  Scattered 
throughout  the  tissue  are  several  large,  deeply  staining,  and  irregular  nuclei, 
and  still  other  cells  containing  quantities  of  coal-black  pigment.  One  is  able  to 
trace  the  transition  between  the  ordinary  muscle-fibers  and  the  deeply  staining 
masses.     The  ])icture  is  one  of  typical  sarcomatous  transformation  of  a  myoma. 

August  27,  1908,  more  than  five  years  after  the  operation,  the  patient's  phy- 
sician, Dr.  James  Cooi)er,  writes,  "She  is  quite  well." 

C.  H.  I.  No.  78.     Path.  No.  7555. 

Sarcomatous  transformation  of  an  interstitial 
myoma;  secondary  and  ]i  u  r  e  sarcomatous  nodule  on 
the  posterior  surface  of  t  h  e  u  t  e  r  us.  M  y  o  m  a  t  o  u  s 
n  o  d  VI 1  e  with  sarcomatous  invasion  in  t  h  e  1  c  f  t  b  r  0  a  d 
ligament   (Figs.  125,   126,  127,  128,  and  129). 

L.  T.,  white,  married,  aged  fifty.  Seen  in  consultation  with  Dr.  Lilian  A\'elsh 
and  admitted  May  30,  1904.  For  several  years  the  patient  has  suffered  from 
uterme  fibroids  and  also  from  a  growth  in  the  right  breast.  Recently  the  growth 
in  the  pelvis  has  materially  increased  in  size.  There  has  been  a  great  deal  of 
pain  extending  do^^^l  the  left  leg.  Examination  under  anesthesia  shows  the 
uterus  to  be  considerably  enlarged,  and  extending  off  from  it  is  a  large  mass  in- 
volving the  left  broad  ligament. 

Operation.  On  opening  the  abdomen  we  found  the  uterus  considerably  en- 
larged, and  attached  to  its  posterior  surface  was  a  cockscomb-like  growth  fully 
15  cm.  in  length  (Figs.  125  and  126).  To  the  left  of  the  uterus  and  attached  to 
it  was  a  mass  filling  the  entire  broad  ligament  (Fig.  127),  and  extending  up  to 
the  pelvic  brim.  This  was  thought  to  be  malignant,  and  no  attem})t  was  made 
to  remove  it.  A  supravaginal  hysterectomy  seeming  preferable  as  a  palliative 
procedure. 

June  11,  1904.  After  having  carefully  examined  the  uterus  macroscopically 
we  came  to  the  conclusion  that  the  growth  was  benign,  and  therefore  determined 


MYOSARCOMA    OF    THK    UTKRUS. 


185 


to  rt'iiiuvc  the  large  mass  in  the  left  broad  ligament.  A  long  incision  was  made 
parallel  to  the  left  Poupart's  ligament  and  extending  up  to  the  left  flank.  The 
])eritoneum  was  pushed  upward  and  forward  until  we  came  in  contact  with  the 
mass.  This  was  dissected  out  with  little  or  no  hemorrhage ;  in  fact,  no  ligatures 
were  necessary.  As  the  pelvic  cavity  was  accidentally  opened  low  do\ra,  a 
small  drain  was  carried  to  the  bottom  of  the  wound.  The  i)atient  made  a  per- 
fectly satisfactory  recovery.  She  was  advised  to  return  in  a  few  months  to  have 
the  breast  amputated,  but  procrastinated,  ^^'hen  she  came  back  in  March,  1908, 
there  were  inoperable  car- 
cinomata  of  both  breasts. 

Path.  No.  7555.  The 
uterus  is  fully  three  times 
the  natural  size  and  is 
somewhat  globular.  The 
portion  present  is  8  cm.  in 
length,  9  cm.  in  breadth, 
and  9  cm.  in  its  antero- 
posterior diameter.  Its 
anterior  surface  is  smooth. 
Its  ])osterior  surface  is 
prominent,  apparently  ow- 
ing to  the  presence  of  a  tu- 
mor in  its  walls.  Attached 
to  th(>  |X)sterior  surface  by 
a  narrow  pedicle  is  a  cocks- 
comb-shaped growth,  15 
cm.  in  length.  It  is  sharply 
diffci'cntiated      from       the 

I'k;.       12.'). SARf'OMATOt'S      TRANSFORMATION'      OF      A      MvOMA      WITH      .\ 

uterus.       At    its   Up])er    J)Ole  Skcon-dary  growth  on  thkPostkriorSurfack  of  thk  uterus. 

it    is   adherent    and  forms  a  Path.  No.  755.5.     The  uterus  is  considerably  enlarged  and  on  its 

jjosterior  surface  is  a  growth  roughly  resembling  a  cockscomb.  Histo- 
depreSSion  on  the  fundus.  logic  examination  showed  it  to  be  a  pure  .sarcoma  (Fig.  129>.  The 
TVTnar    ita    tnuldlo     if     i  •    •  1  •  <lotteil   lines  indicate  the  confines  of  a  myosarcoma  in   the  left  broad 

.Near  us  mUKUe  n  is  aiSO  ii^,.„„e„t.  For  the  interior  of  the  uterus,  see  Fig.  120.  For  the  mass  in 
attached     to    lllC    lltcl'US  b\'        the  left  broad  ligament,  see  Fig.  127. 

a  broad  |)c(liclc.    Tlic  lower 

half  is  sc|)ai'atcd  I'roiii  llic  ulciiis  by  an  itilci\al  of  fully  5  iiiiii.  The  lower  end 
has  lain  decj)  in  Dtjuglas'  pouch,  and  has  molded  itself  to  t  he  suiface  of  the  sacrum 
(Fig.  12()).  This  cocksconib-like  growth  \aries  from  ."!  to  5  cm.  in  bi-eadth  and 
projects  from  2  to  .'^  cm.  from  the  suii'ace  of  the  uteiHis.  It  has  a  lobulated 
a])i)earance.  due  to  the  coarse  and  Inie  molding  of  the  sui'face.  ( )n  section  the 
growth  in  places  clo.sely  resembles  a  myoma;  at  othei-  ]»oiiits  it  is  very  homo- 
geneous, showing  little  sti'iation,  and  has  an  appearance  suggesting  sarcoma. 
On  .section  ol'  the  utei-us  nearly  ihe  eiiliie  ea\ily  is  I'ound  lilleil  with  a  gi'owlh 
■1.5  cm.  in  iliaineter  and    somewhat    irregular.      It    is    coinijosed    of    lobulations 


186 


MVoMATA    OF    TllK    ITKHUS. 


\vliicli  have  smooth  siu-faccs  and  vary  from  1  to  o  mm.  in  diameter.  On  section 
this  growth  mitiht  he  taken  for  a  degenerating  myoma  or  for  a  sarcoma. 

On  examination  of  the  hardened  uterus  the  walls  are  found  everywhere  in- 
filtrated by  the  growth,  which  in  some  places  suggests  myomatous  tissue,  in 
others  the  homogeneous  appearance  of  .sarcoma.  The  a])i)endages  offer  nothing 
of  interest. 

The  mass  from  the  left  broad  ligament,  which  was  removed  at  the  second 
operation,  is  1.3  cm.  in  length,  8  cm.  in  breadth,  and  approximately  8  cm.  in 


/ 

Myoma  ^  sarcoma 


Fig.  120. — Myosakcoma  ok  thk  Body  of  thk  I'tkris  \viih  a  Skcondaky  .\xd  I'lre  Sarcomatous  Cockscomb- 
like Growth  on  the  Posterior  Surface.  (|  nat.  size.) 
Path.  No.  7555.  The  uterus  has  been  opened  anteriorly.  Behind  the  uterus  is  the  cockscomb-like 
sarcoma.  (See  Fig.  125.)  Occupying  the  body  of  the  uterus  is  a  rather  diffuse  myoma,  which  on  histologic  ex- 
amination showed  marked  hyaline  degeneration  and  definite  sarcomatous  transformation  of  the  muscle-fibers 
(Fig.  128).  The  cockscomVj-like  growth  is  attached  to  the  posterior  surface  of  the  uterus  by  a  broad  iiedicle,  which 
consists  essentially  of  a  pure  sarcomatous  growth  (Fig.  129). 


thickness.  It  presents  a  markedly  lol)ulate(l  ap]X'arance.  These  lobul(\s  vary 
from  a  j)in-])oint  to  \\  cm.  in  diameter;  they  have  a  mottled  apix'ai'ance  in  places, 
and  are  made  up  of  secondary  lobules  not  more  than  1  mm.  in  diameter.  On 
section  some  portions  of  the  growth  ])resent  the  typical  pictui'e  of  myoma;  others 
are  homogeneous,  mottled,  and  strongly  suggest  sarcoma.  The  center  of  the 
growth  contains  much  blood.  At  the  upper  end  of  the  growth  and  lying  over  the 
i)ifurcation  of  the  pelvic  vessels  is  a  lobular  nodule,  4  by  ;U'm.  (Fig.  127).  This 
on  section  aj)])ears  to  i)e  a  myoma,  although  at  operation  it  was  su])posed  to  bo 
an  enlarged  and  hardened  lymph-gland. 


MYOSARCOMA    OF    THE    UTERUS. 


187 


liistulogic  Exaiiiinatioii. — Sections  from  the  uterine  niueosa  siiow  that  the 
cen-ical  glands  arc  perfectly  normal  and  that   the  surface  epithelium  of  the 
cervix  is  intact.     In  \hv  body  of  the  uterus  the  surface  e])ithelium  is  still  i)rc- 
served.      The    glands     are     normal. 
The  stroma  just  beneath  the  surface 
shows  some  edema  and  there  is  some 
slight  dilatation  of  the  glands.     The 
uterine  mucosa  can  be  traced  directly 
up  to  the  growth  occupying  the  fun- 
dus and  encroaching   on  the  cavity. 
This  growth  in  the  hjwer  portion  pre- 
sents a    typical  myomatous  picture. 
The  greater  part  of  the  myoma  has, 
however,  undergone  hyaline  degenera- 
tion, only  a  few  nuclei  remaining. 

Sections  from  the  body  of  the 
uterus,  also  through  the  growth,  like- 
wise show  much  hyaline  degeneration. 
We  note,  however,  that  the  nuclei 
that  still  remain  in  this  hyaline  ma- 
terial, here  and  thei'e  show  an  increase 
in  size,  being  two  or  three  times  as 
large  as  normal  and  staining  rather 
deeply  (Fig.  128).  In  other  areas, 
where  the  myomatous  tissue  is  still 
well  preserved,  we  have  a  rather 
active  condition  of  the  cells,  although 
the  buntUes  are  still  pei-fectly  pre- 
si'rved.  The  nuclei  are  here  also  two 
or  three  times  as  lai'ge  as  normal  and 
stain  deeply.  Tli;il  this  ;ilterati()ii  is 
going  on  ill  the  bundles  and  cells  is 
perfectl}'  clear,  as  the  outline  of  the 
bundles    is    in    no  wav  distorted.      In 


127.  I'm;  Louui.atki)  and  .Myo.matous  Nodui.f 
Hi  Mnvi;i>  iKOM  TiiK  LEfT  Broad  Ligamknt  in 
i-'ii;.  Hi'),      li  riat.  size.) 

Path.  No.  7555.     This  nodule  was  shellcil  >>iil  of  llii- 
li'fl    broad  liKaineiit   twelve  days    after    removal   of    the 
uterus.     .\ii  incision  wtLs  made  parallel  to  ami  just  above 
I'ouparf's     ligament,     'riie    peritoneum    wa.s    (cradually 
)t  her    portions    ol      the    !J,ro\\tll    we    lllld        pushed    medianward    vnitil  the  nodule  was  perfectly  free. 

It  was  removed  without  it  beiuK  necessary  to  control  any 
bliKHl-ve-s-seU.  The  small  and  partially  constricteil  nodule 
(I  was  at  first  thoUKht  to  he  an  eidarKed  Klaiul,  but  in 
reality  it  formeil  part  of  the  lurKC  nodule.  Histologic  ex- 
aTuiiialioii  showe<l  that  the  growth  was  a  myonui  with 
marked  liyalliu>  ili'Reiieration.  It  also  containeil  tvpical 
sarcomatous  tissue. 


a  totally  different  ])icture.      WC  ha\-e 

scattered     throughout      tin'      muscle 

masses  of  cells  that  at  first  sight  look 

like     carcinoma     nests.       ( )n    careful 

scrutiny  it  is  found,  howexcr.  that  the 

individual  nuclei    fonning  these  nests  are  unifoi'iii  in  si/e  throughout,  and  that 

they  come  out    mucli    more  clearly  than    is   iisu;il  in   carcinoma,  each  cell  being 

sharply  circumscribed.     The  growth  wduld  undoubtedly  be  taken  for  carcinoma. 


188 


MYOMATA    OF   THE    UTERUS. 


The  true  character  is  well  shown  in  the  cockscomb-like  growth  attached  to 
the  posterior  surface  of  the  uterus.  Here  we  have  a  homogeneous  sea  of  cells 
divided  by  a  framework  of  connective  tissue  just  sufhcient  to  carry  capillaries 
(Fig.  129).  The  individual  cells  have  oval  vesicular  nuclei,  and  in  the  entire 
field  ])racticall>-  all  are  of  the  same  size  and  show  the  same  staining  properties. 
The  picture  here  is  one  of  typical  sarcoma.  The  character  of  the  growth  would 
also  indicate  sarcoma.  If  we  were  dealing  with  carcinoma,  we  would  not  for  a 
moment  expect  the  entire  cockscomb-shaped  growth  to  be  firm  in  texture  and 
show  at  no  point  the  slightest  tendency  to  break  down.     This  entire  growth  is 


.-^^.^^ 


,5  ^^ 


k  'a 

Fig.  128. — Commencing  Sarcomatous  Transformation  01  Myomatous  Tissue.  (X  100  diam.) 
C.  H.  I.,  No.  78.  Path.  No.  7555.  The  section  is  from  the  submucous  myoma  seen  in  Fig.  126.  At  a  the 
tissue  has  undergone  ahnost  complete  hyaline  degeneration.  At  b  are  cross-sections  of  muscle-fibers  of  the  usual 
size.  Over  the  area  indicated  by  c  the  nuclei  of  the  muscle-fibers  are  two  or  three  times  as  large  as  usual  and 
stain  deeply.  In  the  area  indicated  by  d  the  nuclei  are  still  larger,  suggesting  a  rather  active  process.  For  the 
typical  sarcomatous  develoi)rnent,  see  Fig.  129. 


made    ii])  of    tvpical    sarcomatous    tissue.      The    differentiation    is    particularly 
well  l)r()Ught  out  by  the  van  (iieson  stain. 

The  nodular  mass  shelled  out  from  the  left  broad  ligament  consists  for  the 
most  part  of  a  myoma  that  has  un(l(>rgone  almost  comi)lete  hyaline  degeneration. 
Little  tufts  of  muscle-fibers  still  persist,  esix-cially  around  the  blood-vessels. 
About  nine-tenths  of  the  field  consists  of  hyaline  tissue.  In  these  hyaline  areas, 
however,  we  find  cells  sometimes  four  or  five  times  the  usual  size,  the  central 
nuclei  being  surrounded  l)y  a  broad  zon(>  of  fine  dark  dots,  looking  very  much 
like  ])lasma  cells.  Other  ])ortions  of  this  broad  ligament  growth  are  totally  dif- 
ferent. Here  the  cells  have  undergone  ccjagulat ion  necrosis,  but  one  still  makes 
out  areas  of  malignant  cells  similar  to  those  in  the  cockscomb-like  growth.     In 


MYOSARCOMA    OF    THK    I'TKRUS. 


189 


Still  other  portions  of  the  growtli  we  iiiid  the  iiiu.scular  elements  in  the  hyaline 
areas  staining  very  sharply  and  showing  a  tendency  to  increase  in  size  and  to 
augment  their  supply  of  chromatin. 

The  nodules  situated  in  the  bifurcation  of  the  iliac  vessel  are  composed  of 
fibrous  tissue  and  of  nests  of  sarcoma  cells.  In  this  specimen  we  have  at  certain 
points  a  glandular  arrangement.  No  lymphoid  elements  can  be  detected,  con- 
sequently it  is  not  a  lymphatic  gland  that  has  been  invaded  by  the  new  growth. 

"We  have  here,  then,  a  uterus  twice  its  natural  size,  and  with  the  fundus  oc- 
cupied by  a  lobulated  growth  which  penetrates  the  uterine  wall  and  forms  a 
cockscomb-like  giowth  on 

the    outer    surface.       \\c  t> 

also  have  a  large  irregular 
growth  situated  between 
the  folds  of  the  left  broad 
ligament.  The  growth  oc- 
cupying the  body  of  the 
uterus  is  to  a  great  extent 
composed  of  a  finely  lobu- 
lated myoma  which  has 
undergone  partial  hyaline 
degeneration.  The  fibers 
of  this  myoma  in  certain 
areas  show  a  marked  ten- 
dency to  proliferate  and 
become  malignant,  not- 
withstanding the  fact  that 
muscle-bundles  are  still 
well  preserved.  The  outer 
portions  of  this  growth 
consist  of  tissue  in  no  way 
distinguishable  fioni  sai- 
coma.  The  cockscoml)- 
like  growth  is  sarcomatous. 
The  left  intraligamentary 
nodule  lias  to  a  large  extent  nndei-gone  hyaline  t ransfonnation.  but  it  also  has 
been  invade(l  by  a  new  growtii  wiiich  started  from  the  uterus.  We  have  been 
unal)le  to  find  any  similar  case  in  the  literature.  In  all  probability  the  myoma 
was  the  i)nmary  factor.  an<l  this  myoma  is  undergoing  .sarcomatous  transforma- 
tion, and  we  believe,  although  we  ai'e  not  in  ;i  |iosilion  to  prove  il.  thai  the  sar- 
comatous cockscomb-like  growth  of  the  uterus  is  secondary  to  the  sarcomatous 
degeneration  of  the  myoma,  and  that  it  is  nothing  more  tiian  an  outgrowth  of  the 
sarcoma  in  the  uterus.  i'Voin  ;i  clinic;il  standpoint  it  is  partieuiailv  interesting 
that  this  patient  is  perfectly  well,  as  far  as  the  pelvic  lesion  is  concerned. 


'm^^M 


Fui.  129. — .\  Sarcoma  that  has  Dkvki.oped  from  an  Interstitial 
Myoma.  (X  125  diam.) 
C.  H.  I.  No.  78.  Path.  No.  7555.  The  section  is  taken  from  the 
cockscomb-shaped  sarcomatous  growth  on  the  posterior  surface  of  the 
uterus  seen  in  Fig.  12<).  The  mahgnant  changes  first  commenced  in  an 
interstitial  an<l  partiall.v  submucous  myoma  and  tlie  seci>ntlary  growth 
wa.s  a  pure  sarcoma,  a.s  seen  in  tiiis  i)icture.  The  cells  are  large  and 
remarkably  uniform  in  size.  This  sea  of  cells  has  delicate  strands  of 
stroma  (a)  scattere<l  throughout  it  and  dividing  the  growth  into  alveoli 
of  various  sizes,  as  indicated  by  b.     The  picture  is  t.vpical  of  sarcoma. 


190  MYOMATA    OF   THE    UTERUS. 

C.  H.  I.,  W.,  Jan.  22,  1903.     Path.  Nos.  6421-8370. 

S  u  j)  r  a  V  a  <2;  i  n  a  1  h  y  s  t  c  r  v  c  t  o  in  y  s  u  j)  p  o  s  e  d  1  y  for  si  m  p  1  e 
i  n  t  ('  r  s  t  i  t  i  a  1  and  subperitoneal  m  y  0  ni  a  t  ti  .  Two  y  e  a  r  s 
later  sudden  collapse  due  to  hemorrhage  from  a  sar- 
c  o  m  a  developing  from  1  h  c  c  e  r  v  i  c  a  1  s  t  u  m  p  (Fig.  130). 
Reexamination  of  the  o  r  i  g  i  n  a  1  t  u  m  o  r  s  h  o  w  e  d  t  y  p  i  c  a  1 
sarcomatous  t  r  a  n  s  f  o  r  m  a  t  i  o  n  of  the  myoma  (Fig.  131). 
L  a  t  e  r  intestinal  o  h  s  t  r  u  c  t  i  o  n  ;  a  r  t  i  fi  c  i  a  1  a  n  u  s  wit  h 
e  o  m  ])  1  e  t  e  control.  Death  e  i  g  h  t  m  o  n  t  h  s  a  f  t  e  r  the 
second    o  ])  e  r  a  t  i  o  n  .* 

Mrs.  V^'..  white,  aged  forty-two.  Seen  in  consultation  on  January  22,  1903. 
For  several  years  the  mcnsti-ual  periods  have  been  exceedingly  free.  From  time 
to  time  she  has  been  treated  for  dyspepsia  and  for  some  cardiac  lesion,  but  not 
until  recently  has  any  abdominal  enlargement  been  detected.  She  is  well 
nourished,  but  is  exceedingly  pale.  The  mucous  membranes  are  blanched  and 
the  hemoglobin  is  30  per  cent.  On  vaginal  examination  the  cervix  is  found  to  l)e 
normal,  but  filling  the  vaginal  vault  and  extending  half-way  to  the  umbilicus  is 
an  irregular  myomatous  uterus.  Above  and  to  the  right  is  a  globular  mass  the 
size  of  a  kidney.  One  of  the  most  interesting  phenomena  is  a  thrill  felt  by  the 
examining  finger  along  the  course  of  the  left  uterine  vessels. 

0{)eration.  The  uterus  was  brought  up  without  much  difficulty,  and  the 
large  mass  felt  in  the  region  of  the  liver  proved  to  be  a  suliperitoneal  and  pedun- 
culated myoma.  The  uterus  was  removed  from  left  to  right.  The  left  tube  and 
ovary  were  not  disturbed.  The  patient  stood  the  operation  well  and  lost  very 
little  blood.  Phlebitis  developed  some  days  after  operation,  but  did  not  retard 
her  progress  very  nuich.  Within  a  month  her  color  had  returned,  and  in  less 
than  three  months  she  appeared  to  be  in  perfect  health.  I  saw  her  on  January  21, 
1905,  and  she  was  in  excellent  condition. 

Second  operation,  February  17,  1905.  The  patient  felt  perfectly  well  and 
went  to  mai'ket  yesterday  morning.  About  1  p.  m.  she  was  taken  with  pain  in 
the  lower  abdomen,  and  a  little  later  almost  fainted  while  at  stool.  Dr.  Nathan 
11.  Gorter  was  called  to  see  her  and  advised  immediate  removal  to  the  hospital. 

On  examination  under  anesthesia  we  found  the  pelvis  partly  filled  with  a 
mass  the  size  of  a  small  cocoanut.  This  a|)])arently  involved  the  left  side  more 
than  the  right.  The  left  ovary  having  been  saved  at  the  previous  operation,  we 
thought  that  this  tumor  was  certainly  ovarian  in  origin.  On  opening  the  abdo- 
men the  left  ovary  was  found  to  be  ])erfectly  normal,  but  projecting  from  the 
stump  of  the  cervix,  and  extending  down  between  the  cervix  and  the  rectum,  was 
a  definite  sarcomatous  nodule  fully  10  cm.  across  (Fig.  130).  This  was  somewhat 
lobulated.  It  had  been  slightly  lacerated  and  free  bleeding  had  occurred.  We 
removed  at  least  a  quart  and  a  half  of  free  blood  and  clots  from  the  alxlominal 

*  CiiUen,  Thomas  S.:  riarcoiiiatous  Traiisforinatiim  of  Myoinata,  .lour.  Am.  Med.  Assoc, 
March  10,  1906. 


.\n()SAK(<).MA    OV   THK    UTERUS. 


191 


cavity.  Her  sudden  discoiiitort  had  evidently  been  due  to  partial  tearing  of  the 
growth.  \\\'  wei'e  al)le  to  peel  the  growth  out  to  a  great  extent.  l)Ut  it  was  im- 
possible to  remove  it  in  its  eiitiivty. 

The  left  lobe  of  the  liver  was  shar]).  the  right  lobe  very  blunt  and  thickened. 
We  thought  we  were  dealing  with  a  hei)atic  metastasis,  but  on  contimiing  the 


Fifi.  130.     S\i(r(iM\  1)kvi;i.oi'1\(;  in  tiik  Ckrvicai.  Sump. 
Path.  .No.  s:i7().     'I'he  pelvis  i.s  viewe<l  from  ntjove.     RisitiR  from  the  pelvi.'^  between  the  lihuliler  uinl  the  rectum 
i.s  a  smooth,  h>l>iihite<l  Rrowth  pre.><eiitiii({  a  somewhat  8"arreil  appenraiiee.     To  the  left  is  the  intact  and  iiorinjil 
left  ovary.     The  riKlit  appetiiiaRe.s  were  removeil  at  the  first  operation. 


incision  U|)ward,  tound  there  was  merely  thickening  of  the  lixcr.  The  omentum 
was  free.      The  ap|)endi\   was  reinoxcd. 

The  condition  is  |>articulaiiy  interesting  when  we  i-cmcmbci-  that  the  uterus 
had  been  i'enio\-ed  two  years  before  ami  that  the  patient  had  ri'inained  j)erfectly 
well. 

Postopeiatix'e  History.  The  patient  was  readmittetl  to  the  ("hui'ch  Home  on 
.\ugust  21,  1!)().").      j'or  the  )(receding  foui-  or  ti\-e  weeks  she  hail  great  ditlicultv 


192  MVOMATA    OF    THK    I'TERUS. 

in  securing  an  evacuation  of  tiie  bowels.  On  examination  we  found  the  pelvis 
practically  filled  with  a  new  o;i()\\tli,  rendering  necessary  the  making  of  an  arti- 
ficial aims.  The  bladder  was  definitely  implicated  by  the  growth  and  the  urine 
contained  large  quantities  of  blood.  I  made  an  incision  through  the  left  rectus, 
brought  out  the  sigmoid  tiexure,  cut  it  in  two,  closed  the  lower  (>nd,  brought  the 
upper  end  out  through  the  rectus,  passed  it  outward  beneath  the  sheath  of  the 
rectus  for  about  an  inch  and  a  half,  then  made  a  longitudinal  section  through  the 
sheath  of  the  rectus  and  through  the  fascia  to  the  skin,  attaching  the  bowel  to 
the  skill.  The  bow(>l.  therefore,  was  brought  upward,  then  outward,  and  then 
U])wartl  again.  The  patient  experienced  a  great  deal  of  relief.  Her  bowels 
moved  once  or  twic(>  a  day,  but  she  had  practically  alisolute  control,  as  there  was 
no  escape  of  fecal  matter  excejjt  at  stool.  She  improved  considerably.  Occa- 
sionally there  was  some  discomfort  from  the  rectal  tenesmus  due  to  the  ever-in- 
creasing growth  pressing  on  the  remaining  portion  of  the  rectum;  otherwise  she 
was  comfortable.  She  remained  in  the  hospital  until  October  1st.  During  the 
last  two  weeks  of  her  life  she  became  much  weaker  and  died  October  30,  1905. 

Path.  X  o  .  S  o  7  0  .  A  s  a  r  c  o  m  a  t  o  u  s  g  r  o  \\- 1  h  developing 
fro  m  t  h  e  c  e  r  \'  i  c  a  1  s  t  u  m  \) .  The  specimen  (Fig.  130)  consists  of  a 
mass  of  tissue,  10  x  8  x  5  cm.  It  is  somewhat  lobulated,  rather  smooth,  and 
on  its  under  surface  has  a  basal  attachment  extending  over  an  area  5x5  cm. 
The  tissue  is  of  brain-like  consistence,  yellowish-white  in  color.  It  is  very  friable. 
On  section  the  mass  is  found  to  contain  a  large,  irregular  ar(>a  of  hemorrhage. 
At  one  point  is  a  cystic  space  2  x  1.5  cm.  This  is  divided  by  trabecuhe  into 
smaller  spaces  and  is  filled  with  blood-clots.  The  general  character  of  the 
growth  is  clearly  evident  without  histologic  examination. 

Histologic  Examination. — The  tumor  is  found  to  be  made  up  of  a  sea  of  cells. 
Most  of  these  have  oval  vesiculai-  nuclei  and  bear  a  striking  resemblance  to  those 
of  muscle-fibers.  Th(^  cells  themselves  are  spindle-shaped,  with  deeply  staining 
nuclei,  two  or  three  times  the  natural  size.  Others  are  irregular  and  also  stain 
deepl>'.  In  places  we  have  masses  of  protoplasm  containing  five  or  six  deeply 
staining  nuclei.  At  other  points  there  are  giant-cells  in  which  the  miclei  are  not 
over  one-third  the  usual  size.  In  places  are  seen  spindle-cells  undergoing  divi- 
sion. There  are  large,  irregular  plaques  of  protoplasm  containing  fragmented 
nuclei  and  cells  showing  typical  miclear  figures.  The  micleus  itself  is  sometimes 
divided  into  five  or  six  young  nuclei.  The  blood-vessels  are  large  and  abundant. 
The  majority  of  them  appear  to  be  veins.  Some  are  filled  with  thrombi  and  the 
tumor  cells  are  gradually  obliterating  them.  In  fact,  dividing  tumor  cells  can  be 
demonstrated  lying  free  in  such  blood-vessels.  In  some  places  the  tissue  is 
much  rarefied.  In  such  areas  giant-cells  are  })articularly  abundant.  The 
growth  is  essentially  a  spindle-celled  sarcoma  which  shows  a  marked  tendency 
toward  giant-cell  formation. 

Path.  No.  6421.      Description  of  the  original  tumor. 

The  specimen  (Fig.  131)  consists  of  a  globular  uterus,  approximately  18  cm. 


MYOSAIiCOMA    OF    THH    UTKRUS. 


193 


ill  diameter.  It  is  smooth  and  <ilistening.  On  the  surface  one  or  two  nodules 
can  be  detected.  Attached  to  the  riijht  coriiu  is  a  ki(hiey-.shaped  subperitoneal 
nodule,  13  cm.  in  leiijith  and  s  cm.  in  breadth.     It  is  attached  by  a  pedicle,  2.5  x 


Fir;.  l.'Jl. — SviicoMAToi's  Tkanskokmation  OF  A  Utkrink  Myoma.  Si'HRAVAcilSAi,  .Xmi'ttatkin  wnii  IUtiks 
OK  THK  (IhOWTII  IN  THK  Ckkvicai,  .STrMP.  (J  iiat.  f<ize.') 
Path.  No.  0421.  The  picture  represents  a  loiiKitiiiiinal  seotinti  throuRh  the  entire  uterus,  a  is  the  upper 
limit  iif  the  uterine  cavity;  b,  the  lower  or  cervical  portion.  It  is  thus  .seen  that  the  inyonia  occupyinR  the  poster- 
ior wall  i)rojpcte<l  into  the  uterine  cavity  ami  put  the  mucosa  on  tension.  The  myomatous  niMlule  is  api)roximatcly 
circular  and  in  many  places  yielils  the  ustnil  myomatous  striation.  ,\t  c  is  an  area  of  typical  hyaline  ileKoneration, 
recoKnizeil  liy  its  homogeneous  appearance.  .Vt  numerous  points  inilicateil  hy  il  we  fiml  sharply  outlined  jtranular 
or  spongy  area.s,  which  are  at  once  recognized  lus  sarcomatous.  .Vt  e  along  the  outer  margin  of  the  myoma  are 
area.s  of  sarcoma,  and  the  tissue  lictwccn  f  aiicl  f  is  partly  myonnitous,  partly  sarcomatous;  g  is  an  area  of  calcifi- 
cation. 


1 ..")  cm.,  and  is  freely  iiio\able.  The  utei-ine  cjiNily  is  17  cm.  in  length,  and  is 
markedly  con\'ex,  owint:;  lo  the  fact  that  the  tumor  projects  inward  from  the 
posterior  wall.      The  mucos;i  on  the  whole  looks  noi'in.al.  but  is  atrophic.     Near 


13 


194  MYO.MATA    OF    THK    UTHUUS. 

the  fundus  it  has  uiKlcrt^oiic  in  some  i)l:u'cs  ahnost  (•()inj)h'te  atrophy,  the  growth 
in  the  posterior  wall  shining  through. 

The  enlargement  of  the  uterus  is  due  chiefly  to  a  circular  nodule  13.5  cm.  in 
diameter,  occupying  the  posterior  wall.  This  nodule  is  almost  spherical.  The 
central  portion  has  in  ]iart  undergone  typical  hyaline  degeneration,  as  is  evi- 
denced by  large  and  small  spaces  traversed  by  delicate  trabccuhr.  On  careful 
examination  there  are  several  areas  presenting  a  homogeneous  spongy  ap- 
pearance (Fig.  \:\\).  These  form  a  part  of  the  myomatous  tissue.  They  vary 
from  1  to  4  cm.  in  iliameter,  are  irregular  in  their  distriljution,  and  have  un- 
doubtedly develojx'd  from  the  myomatous  tissue.  They  give  the  characteristic 
appearance  of  sarcoma  and  aic  distributed  throughout  the  solid  portion  of  the 
tumor,  being  also  intermingled  with  areas  of  hyaline  degeneration.  Macroscopi- 
cally  one  is  able  to  (liagnos(>  with  absolute  certainty  a  sarcoma  developing  from 
the  myoma.  The  uterine  walls  posterior  to  the  tumor  vary  from  1  to  1.5  cm.  in 
thickne.><s,  and  in  some  places  there  is  a  covering  of  from  2  to  5  mm.  of  uterine 
muscle  separating  the  growth  from  the  mucosa. 

Histologic  Examination. — The  areas  indicating  hyaline  degeneration  are  en- 
tirely devoid  of  nuclei.  Here  the  tissue  has  undergone  the  usual  complete  hya- 
line transformation.  Many  sections  have  been  taken  from  the  areas  suggesting 
sarcoma.  In  the  majority  of  these  most  of  the  elements  have  undergone  com- 
plete coagulalion  necrosis.  Here  and  there,  however,  in  the  vicinity  of  the 
blood-vessels  are  a  good  many  small  round  cells.  In  some  of  the  sections  in 
which  there  is  incomplete  hyaline  degeneration  a  good  many  muscle-fibers  are 
still  preserved  and  there  are  quantities  of  mast  cells.  The  nuclei  of  the  muscle- 
fibers  show  considerable  variation  in  size  and  staining  properties.  One  is  in- 
stantly remind(>d  of  a  sarcomatous  transformation.  In  the  more  characteristic 
sarcomatous  areas,  where  the  cells  are  still  preserved,  we  find  similar  histologic 
changes.  The  miclei  are  four  or  five  times  the  natural  size,  are  irregular  in  out- 
line, and  stain  very  deei)ly.  In  other  places  we  have  very  large,  irregular  cells 
wnth  protoplasm  that  takes  the  eosin  stain  deeply,  and  irregular  nuclei  situated 
in  the  centers  or  at  the  margins  of  the  cells.  Again,  some  cells  contain  six 
or  .s(>veii  nuclei.  The  picture  instantly  suggests  sarcoma,  but  it  is  impossible  to 
tell  with  certainty  whether  the  growth  has  really  started  in  the  muscle-fibers  or 
whether  it  has  originated  from  th(^  connective  tissue.  On  the  whole,  the  evi- 
dences of  musck;  origin  appear  to  be  the  more  reliable.  In  some  of  the  hyaline 
areas  the  blood-vessels  still  persist,  the  endothelium  is  present,  and  the  cells 
of  the  vessels  are  stained  deeply  and  are  irregular,  suggesting  that  the  connective 
tissue  of  the  vessel  wall  is  also  undergoing  a  malignant  change.  The  deeply 
staining  cells  stand  out  in  sharj)  contrast  with  the  surrounding  areas  of  hyaline 
degeneration.  Macroscojjically  and  microscopically  areas  of  calcification  are 
evident.  At  no  point  do  we  find  any  evidence  that  the  sarcoma  extends  beyond 
the  confines  of  the  myoma.  The  specimen  was  examined  in  the  laboratory 
immediately  after  the  first  oi)eration  and  longitudinal  sections  were  made.     In 


MYOSARCOMA    OF    THE    UTERUS.  195 

these  degenerative  changes  were  noted,  but  through  an  unfortunate  circum- 
stance no  further  sections  were  made,  and  it  was  not  until  after  the  second  opera- 
tion, more  than  two  years  later,  that  we  found  the  sarcoma  springing  from  the 
cervical  stump.  When  the  original  tumor  was  again  examined,  even  a  casual 
glance  showed  areas  of  hyaline  degeneration  in  the  myoma  and  also  irregular 
areas  of  typical  sarcoma. 

A  consideration  of  this  case  might  well  raise  the  question  whether  a  complete 
hysterectomy  would  not  be  advisable  in  all  cases.  But  the  supravaginal  opera- 
tion is  the  easier  one;  it  leaves  better  support  to  the  pelvic  floor,  there  is  less 
danger  of  tying  the  ureters,  antl  as  the  blood-supply  of  the  bladder  is  but  little 
interfered  with,  there  is  less  likelihood  of  a  postoperative  cystitis.  The  ad- 
vantages of  the  supravaginal  operation  would  appear  to  more  than  outweigh 
the  objection  that  there  is  an  occasional  occurrence  of  malignant  changes  in 
or  associated  with  myomata.  This  case,  however,  clearly  indicates  that  we 
should  carefully  examine  not  only  the  uterine  mucosa  for  carcinoma,  but  also 
the  myomata  for  sarcomatous  changes  before  the  cervical  stump  is  closed. 

Gyn.  No.  7313.     Path.  Nos.  3673  and  3576, 

A  sloughing  submucous  myoma;  large  spindle- 
celled  sarcoma  occupying  the  anterior  uterine  wall, 
and  implicating  the  uterine  cavity  (Figs.  132,  133, 
and  134).  Formation  of  a  secondary  nodule  in  the 
right  broad  ligament;  small  interstitial  myomata; 
localized  endometritis.  Later  implication  of  the 
cervical  glands  and  j)  r  o  b  a  b  1  y  secondary  growths  in 
the  lungs  and  pleura^. 

L.  H.,  white,  married,  aged  forty-five.  Admitted  October  25;  discharged 
November  29,  1899.  Complaint,  tumor  of  the  uterus.  The  patient  has  been 
married  seventeen  years,  has  had  one  child  and  one  miscarriage.  The  child  is 
fourteen  years  old.  The  patient  had  an  instrumental  labor,  was  in  bed  twelve 
weeks,  and  had  chills  and  some  fever.  Her  menses  commenced  at  fourteen  and 
have  been  regular  every  four  weeks  until  nine  inouths  ago.  They  have  always 
been  profuse,  and  she  has  had  a  great  deal  of  hemorrhage  since  the  tumor  was 
first  noticed.  The  hemorrhage  began  in  April,  1899,  and  the  loss  of  blood  has 
been  almost  continuous,  l)ut  more  marked  at  the  menstrual  periods.  Two 
weeks  ago  she  had  a  chill  and  a  necrotic  subnmcous  myoma,  14  x  8  x  S  cm.  in 
diameter,  was  expelled.  The  tem))erature  was  100.4°;  the  j)uls(>  was  101.  Three 
days  preceding  this  she  had  laboi-like  pains.  ( )n  alxloininal  examination  a 
tumor  is  found  extending  9  cm.  above  the  unihilicus. 

Operation,  November  1,  1S99.  .Vbdoniiiial  liNstei'eetomy.  The  omentum 
was  adherent  to  a  subperitoneal  nodule,  7x7  cm.  It  was  tied  off,  and  the 
entire  mass  lifted  out.  Dense  adhesions  were  cut ,  and  the  uterus  was  amputated 
just  above  the  vaginal  vault.     On  the  right  side  was  a  lai'ge  abscess  full  of  thick 


196  MVOMATA    OK    THE    UTERUS. 

jms.  The  al)sc'Oss  was  situated  Ix'iieath  the  broad  ligaiiicnt  :  it  was  attached  to 
the  rectuin  and  had  burrowed  about  4  ciu.  along  the  vagina  on  the  right  side. 
The  vaginal  vault  was  opened,  and  an  iodoform  gauze  drain  carried  into  the 
vagina.  The  cervix  was  covered  over  with  peritoneum  in  the  usual  way,  and 
tile  abdomen  closed.  The  abscess  originated  in  the  tube.  The  maxinmm  post- 
oju'rative  temperature  was  100.6°.  Tt  reached  normal  on  the  eleventh  day,  and 
the  ))atient  made  a  satisfactory  recovery. 

This  j)aticnt  had  Ix'cn  seen  in  .May,  1S91),  and  inunediate  ojuTation  was 
advised,  but  she  decided  to  wait   until  the  fall,  thinking  that  the  tumor  might 

Path.  No.  3673.  The  specimen  consists  of  a  submucous  myoma,  spontane- 
ously exju'lled  from  the  uterus.  It  is  1.3  cm.  in  length,  and  varies  from  3  to  5  cm. 
in  breadth.  The  surface  is  comparatively  smooth  and  of  a  Ijright  red  color. 
At  the  lower  end  the  tumor  is  jiartially  subdivided  by  a  cleft  2.5  cm.  in  depth. 
The  growth  at  its  base,  where  attachetl  to  the  uterus,  is  3  cm.  in  diameter.  On 
pressure  it  is  firm  and  tough.  At  its  extremity  it  appears  to  be  gangrenous 
and  has  an  exceedingly  foul  odor.  On  section,  it  does  not  present  the  charac- 
teristic appearance  of  myoma.  It  has  a  very  abundant  blood-supply,  some  of 
the  vessels  reaching  2.')  mm.  in  diametei-. 

Histologic  Examination. — In  sections  tak(>n  from  various  portions  of  the 
tumor  no  trace  of  the  mucosa  is  to  be  made  out.  The  .surface  is  entirely  necrotic. 
The  cell-outlines  are  no  longer  visible,  but  just  Ix'ueath  the  surface  are  many 
fragmented  polymorphonuclear  leukocytes.  In  the  deeper  portions  a  few 
nuiscle-fibei's  are  stih  visil)le.  Here  and  there  are  large  irregular  and  deeply 
staining  nuclei.  Scattered  throughout  the  necrotic  ti.s.sue  are  myriads  of  cocci, 
and  .some  of  the  blood-vessels  are  tilled  with  them.  The  deeper  portions  of  the 
tumor  consist  of  non-striped  mu.scle-fibers,  showing  much  diffuse  hyaline  de- 
generation and  a  high  degree  of  vascularity.  The  a])pearances  are  typical  of 
a  sloughing  submucous  myoma. 

Path.  Xo.  3576.  The  specimen  consists  of  an  enlarged  and  irregular  uterus 
with  the  ai)j)endages  intact.  The  uterus,  which  has  been  amputated  through  the 
cervix,  is  15  cm.  in  length  and  15  cm.  broad.  It  has  a  smooth  surface,  and 
anterioi'ly  is  covered  with  peritoneum.  Posteriorly  are  numerous  den.se  ad- 
hesions; attached  to  the  fundus  is  a  soft,  friable  mass,  6x4  cm.  This  can  be  torn 
readily  and  seems  to  be  arranged  in  long  threads.  On  section,  the  great  increase 
in  size  of  the  uterus  is  found  to  be  due  to  a  growth  occupying  chiefly  the  anterior 
wall.  This  growth  reaches  ()  eni.  in  thickness,  is  yellowish  white  in  color,  homo- 
geneous in  consistence,  and  divided  into  smaller  lobules  by  glistening  fibrous 
trabecula-  (Fig.  132).  In  some  j^ortions  this  growth  is  honeycombed  with 
small,  cyst-like  spaces,  varying  from  1  to  7  mm.  or  more  in  diameter.  The 
tumor  is  sharply  outlined  from  the  uterine  muscle,  and  in  the  middle  of  the 
uterus  extends  to  the  mucosa.  Near  the  internal  os  it  is  devoid  of  nmco.sa  and 
lies  free  in  the  cavity.     It  implicates  the  fundus,  but  does  not  encroach  upon  the 


MYOSARCOMA    OF    THE    UTKHl'S. 


197 


post('ri(ji-  wall.  Situatcil  in  the  posterior  wall,  however,  is  an  interstitial  myoma, 
2  em.  in  diameter.  The  uterine  eavity  is  11  em.  in  length.  The  mucosa  of  the 
cervical  portion  is  thin,  and  that  of  the  body  is  als(^  atrophic.  Occupying  the 
right  broad  ligament,  and  intimately  connected  with  the  uterus,  is  a  nodule, 
10  X  9  X  8  cm.  This,  on  section,  consists  of  the  same  liomogeneous  tissue  that 
formed  the  tumor  occu})ying  the  anterior  wall.     The  central  portion  contains 


Fk;.  132. — Sarcoma  of  thk  .Vntkhiou  I  ri;ni\i;  W'ai.i..     (;  luit.  size.) 
Path.  No.  .3.576.     a  i.s  the  outer  coveritiK  "f  iioniial  iiniscle;    h,  the  smooth  homogeneous  sarcomatous  tissue, 
which  is  divided  up  into  large  and  small  islaiuls  hy  the  haruls  of  stroma,  c.     This  stroma  is  fihrillateil,  and  seems 
to  be  composed  of  myomatous  ti.ssue.     Scattered  thniii^rhinit  ilic  s;u<-iimki  arc  iiumv  siiiDnih-wallcd.  cyst-like  siiaces 
(d),  varying  from  1  to  10  mm.  or  more  in  diamcl<'i. 

an  ii'regular,  cysl-likc  ea\it\'  ( i'^ig.  \'.VA),  api)io\imalel>'  o  x  3  cm.,  and  scattered 
throughout  the  growth  -.Wi'  minute  e>'sts. 

( )n  the  right  side  ihctiilic  is  II  cm.  long,  .and  gradually  inci'cascs  in  di.'imcter 
from  i)  mm.  t(j  ^).o  cm.  at  its  distal  cxti'cmity.  It  is  coxcrcd  with  \ascular 
adhesions.  The  o\'ai'y  is  bound  to  the  tube  and  posici'ior  surface  of  the  uterus. 
It  measures  o.o  x  2  cm.,  and  contains  a  small  cyst. 

On  the  left  side  the  appendages  arc  api)ai'cntly  noi'inal. 


198 


MYOMATA    OF   THE    ITHRUS. 


Histologic  Examination. — Sections  from  the  uterine  mucosa  show  that  the 
surface  epithelium  is  intact,  but  that  in  a  few  places  it  is  slightly  thickened. 
Here  and  there  the  surface  is  covered  with  iiolymorj^honuclear  leukocytes,  and 
at  such  points  the  mucosa  is  ivpi-esciit cd  by  granulation  tissue.  In  most  places, 
however,  the  uterine  glands  are  normal,  and  the  stroma,  apart  from  localized 
small-round-celled  infiltration,  shows  little  alteration.  We  have  a  fairly  normal 
nuicous  membrane,  with  foci  of  endometritis.  The  growth  occupying  the 
anterior  uterine  wall   consists  of  laige  ([uantities  of  spindle-cells  ari'anged  in 


Flc.  1.33. — A  I.AHi.h  >AHi<)MATors  Noiui.k  Containinc  an  luRi.cri.AR,  Smooth-wallei)  Cavity  in  its  Centkr. 

(I  nat.  size.) 
Path.  No.  3576  a  represents  the  uterine  muscle,  which  i.s  coarser  than  usual;  h  is  the  sarcomatous  growth, 
which,  although  showing  some  fibrillation  and  whorls,  is  fairly  homogeneous.  Scattered  throughout  the  growth 
are  several  small,  irregular,  cyst-like  spaces,  as  indicated  by  c,  and  the  center  of  the  growth  is  made  up  of  an  ir- 
regular, smooth-walled  cavity,  (d).  Histologic  examination  failed  to  reveal  any  epithelial  or  endothelial  lining  to 
this  space.  The  sarcoma,  while  in  places  intimately  blended  with  the  muscle,  at  other  points,  as  seen  at  e,  is  very 
loosely  connected       At  f  the  sarcoma  has  reached  the  peritoneal  surface,  forming  a  distinct  prominence. 


bundles.  These  ha\'e  been  cut  lengthwise  and  transversely,  and  the  j)icture  at 
first  sight  suggests  a  veiy  cellular  myoma.  But  on  further  examination  it  is 
found  that  many  of  the  nuclei  ai'e  two  or  three  times  the  length  and  double  the 
breadth  of  those  near  them,  and  furthermore,  that  they  stain  intensely.  Careful 
scrutiny  shows  that  even  in  a  single  field  it  is  {)os.sible  to  detect  six  or  more  minute 
nuclear  figures  in  different  stages  of  develo])ment.  Other  sections  contain  myriads 
of  deeply  staining  nuclei.  So  abundant  are  they  in  ])laces  that  they  form  fully 
lialf  the  field.     Large  areas  of  the  growth  have  undergone  complete  coagulation 


MYOSARCOMA   OF   THE   UTERUS,  199 

necrosis,  and  in  the  vicinity  of  such  ])oints  many  of  the  cells  of  the  growth  con- 
tain brown  graiuilar  ])i<z;nient.  In  the  scanty  amount  of  stroma  numerous  small 
round  cells  are  demonstrable.  The  nodule  situated  in  the  right  broad  ligament 
is  of  the  same  character.  The  growth  is,  of  course,  malignant,  and  is  a  spindle- 
celled  sarcoma  (Fig.  134) .  At  one  point  it  is  possible  to  trace  the  gradual  transi- 
tion of  the  muscle-fibers  into  the  sarcomatous  tissue. 

In  this  case,  from  the  general  contour  of  the  uterus  on  bimanual  examination, 
one  would  naturally  render  a  diagnosis  of  myoma.  So  characteristic  was  the 
growth  in  its  outline  that  the  assistant  who  wrote  up  the  gross  description  before 
the  organ  was  opened  spoke  of  it  as  a  myomatous  uterus.  This  assumption 
naturally  would  be  fully  justified  by  the  history  of  the  submucous  myoma. 

The  right  tube  is  the  seat  of  a  subacute  salpingitis;  the  left  tube  is  normal. 


a 


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b 
Fig.    134. — Probabl?:  Sarcomatous  Transformation  of  Bundles  of  Myomatous  Tissue.     (X  80  diain.) 
Path.  No.  3576.     The  section  is  from  the  sarcoma  seen  in  Fig.  132.     The  upper  half  of  the  field,  as  indicated 
by  a,  is  composed  of  myomatous  tissue;   the  lower  part  (b),  of  sarcomatous  tissue;  c  is  also  sarcomatous  tissue,  and 
at  d  the  muscle-bundles  ajjpear  gradually  to  merge  into  the  sarcoma.     Some  of  the  muscle-bundles  have  undergone 
necrosis. 

The  suhs('((U('iit  clinical  history  of  .Mrs.  II.  is  of  iiilci-cst .  \"^\.  (  )sI(T,  in  a  letter 
dated  November  12,  1902,  writes:  "  I  saw  her  with  Drs.  iiuiiii-ichoiise  and  Scott, 
of  Hagerstown,  on  November  1,  1901.  She  iiad  lost  much  in  weigiit.  There 
was  great  pain  in  the  left  side,  dysjniea,  dulness  on  the  left  side  of  the  chest, 
uniform  flatness,  retained  vocal  fremitus,  feeble,  distant  bi'eatliing,  no  disloca- 
tion of  the  heart.  The  glands  were  involved  abo\-e  the  clavicle.  I  think  there 
w^as  no  doubt  of  the  correctness  of  the  diagnosis  made  l)\-  the  doctors  of  secondary 
growth  in  the  lungs  and  ])leura'.  Then  we  found  out  froiiiCullen  that  there  was  a 
sarcomatous  degeneration  of  a  ni\-oma.     She  died  w  few  weeks  later." 


200  MVOMATA    OF    THH    UTERUS. 

Gyn.  No.  12 155.     Path.  No.  8723. 

S  a  r  c  o  111  a  t  o  u  s  t  r  a  n  s  t"  o  r  in  a  t  i  o  n  o  f  t  h  c  111  u  s  c  1  c  -  fi  b  c  r  s 
i  n  0  n  (•  111  y  o  in  a  (Fig.  1  o  0  )  o  f  a  1  a  v  12;  c  in  y  o  111  a  t  on  s  11 1  criis  . 
H  y  s  t  e  roc  t  u  111  y  .  K  c  t  u  r  n  of  patient  with  abdominal 
ni  0  t  a  s  t  a  s  e  s  . 

L.  Q.,  colored,  aged  forty-eight,  married.  Admitted  May  29;  discharged 
June  24.  100").  The  i)atient  complain.s  of  pain  in  the  left  side  of  the  abdomen 
and  also  in  the  back.  Many  of  her  relatives  died  of  tuberculosis.  Her  menses 
l)egan  at  twelve,  were  always  n^gular  u]^  to  two  years  ago,  when  the}'  began 
coming  at  shorter  intervals  and  the  flow  lastetl  fi-oiii  eight  to  ten  days;  it  was 
free,  but  not  painful.  Two  years  ago  they  lasted  as  long  as  three  weeks  at  a 
time.  The  last  period  was  three  months  before  admission.  There  was  excessive 
bleeding,  but  there  has  been  no  hemorrhage  since.  The  patient  has  been  married 
fourteen  years,  has  had  no  childi'eii,  but  one  miscarriage  twenty-three  years  ago. 
There  has  been  a  foul  leukorrheal  discharge  at  times  for  the  ])ast  year. 

Three  years  ago  the  patient  felt  a  small  mass  in  the  right  lower  abdomen. 
It  was  about  the  size  of  a  hen's  egg.  Two  years  ago  this  commenced  to  increase 
in  size  and  to  be  tender  to  the  touch.  It  would  swell  up  and  then  decrease  again. 
About  this  time  she  noticed  a  swelling  in  the  feet,  and  was  told  by  her  physician 
that  .she  had  a  tumor. 

The  tumor  has  aj^parently  grown  much  more  rapidly  during  the  last  few 
months,  but  there  were  no  marked  symptoms  until  about  three  weeks  ago, 
when  the  patient  began  to  conijilain  of  severe  pain  in  the  left  lower  abdomen, 
radiating  to  the  back  and  down  the  left  leg.  For  two  years  she  has  had  some 
difficulty  at  times  in  voiding.  There  has  been  increased  frec{uency,  the  amount  of 
urine  has  been  scant,  and  it  has  been  difficult  to  start  the  flow.  The  patient  has 
had  a  sev(>re  cold  during  the  ])ast  winter.  There  are  no  marked  heart  or  lung 
sym]itoiiis.  though  the  ])atieiit  is  troubled  witli  night-sweats. 
She  has  been  rapidly  losing  in  weight. 

On  admi.ssion  she  is  thin  and  pale.  On  abdominal  examination  a  rounded 
swelling  is  found  extending  from  the  symphysis  to  the  ensiform  cartilage.  Res- 
])iiation  is  markedly  limited.  There  is  a  small  umbilical  hernia.  The  ring 
admits  the  tip  of  the  index-finger,  and  through  it  the  finger  can  be  forced  into 
the  abd(jniinal  cavity  and  can  readily  palpate  a  hard  tumor.  On  bimanual 
examination  it  is  ])0ssible  to  feel  at  least  two  large  tumor  masses.  The  diagiio.sis 
lies  between  a  multinodular  myomatous  uterus  and  an  ovarian  cy.st. 

Operation.  On  opening  the  abdomen  about  two  ounces  of  clear  yellow  serum 
were  found  in  the  abdominal  caxity.  ( )('cupyiiig  the  up})er  ])art  of  the  abdomen 
was  a  large  tumor,  attached  by  a  pedicle.  'A  cm.  in  diameter.  The  tumor  has 
made  a  three-fourths  turn  on  itself.  This  readily  accounts  for  the  j)resence  of 
the  free  fluid.  The  omentum  was  adherent  to  the  upper  pole  of  the  tumor  for  a 
distance  of  14  cm.     Some  of  its  vessels  were  from  1  to  2  mm.  in  diameter.     There 


MYOSARCOMA    OF    THK    ITERUS.  201 

was  one  adhesion  on  the  left  side,  between  the  anterior  abdominal  wall  and  the 
tumor;  this  measured  2  x  0.5  cm.  After  some  dittieulty  the  uterus  was  re- 
moved. Little  or  no  bleeding  occurred.  The  highest  postoperative  temperature 
was  100.6°.     The  patient  made  a  satisfactory  recovery. 

Second  admission:  The  patient  entered  the  hospital  again  on  February  IS, 
1906,  complaining  of  pain  in  the  arms  and  left  side  of  the  abdomen.  When  she 
left  the  hospital  in  June  she  was  in  fair  health,  and  remained  so  until  October  1, 
1905.  She  then  began  to  feel  a  drawing,  tingling  sensation  in  the  hands  and 
finger-tips,  and  on  account  of  poor  circulation  had  to  wear  three  pairs  of  gloves 
during  the  winter.  About  three  weeks  before  admission  she  noticed  her  al)do- 
men  getting  fuller,  so  that  it  was  impossible  for  her  to  wear  corsets.  There  was 
a  ''  sticking  pain"  in  the  right  side  and  also  in  the  back.  There  was  no  fever  and 
no  vomiting.  On  examination  there  was  dulness  in  the  right  side,  and  continuous 
with  the  liver  and  extending  over  as  far  as  the  left  of  the  nipple.  Occupying 
the  right  upper  abdominal  quadrant  was  a  large  firm  mass  which  had  thick, 
rounded  margins.  On  its  inner  side  was  a  notch  resembling  that  between  the  lobes 
of  the  liver  or  the  hilum  of  the  kidney.  The  mass  was  so  large  that  it  was  only 
slightly  movable.  It  was  very  distinct  posteriorly  in  the  flank.  A  renal  catheter 
was  introduced  and  the  kidney  injected.  Injection  of  9  c.c.  of  fluid  brought  on 
pain,  apparently  located  in  the  lower  part  of  the  tumor.  A  bladder  examination 
showed  nothing  aljnormal.  At  this  time  it  was  impossible  to  tell  the  exact 
character  of  the  tumor,  as  the  changes  in  the  myoma  had  been  totally  over- 
looked in  the  laboratory.  This  was  due  to  the  fact  that  the  tumor  was  supposed 
to  be  nothing  more  than  a  simple  myomatous  uterus,  so  that  instead  of  making 
a  systematic  examination  of  each  myomatous  nodule,  the  pathologist  had  merely 
0])en(Kl  the  uterine  cavity  and  split  the  larger  nodules.  The  patient  shortly 
aftei'ward  left  the  hospital,  although  she  had  a  temperature  of  101°  F.  and  had 
been  lying  in  bed  in  a  listless  condition. 

March  2(S,  1906:  The  ])atient  entered  St.  .Joseph's  llosi)ital  to  be  exaiiiiiied. 
She  had  lost  greatly  in  weight  and  strength  since  leaving  the  Johns  Hopkins 
II()S])ilnl.  llei'  face  was  much  emaciated,  the  libs  wei'e  prominent,  and  the 
abdomen  was  much  distended  with  free  fluid.  Se^'eral  irregular  nodules  were 
felt  in  the  abdomen.  At  this  time  some  skin  metastases  were  .seen  in  \\\v  ab- 
dominal wall.  The  patient  was  tappecl  hiter,  and  a  small  amount  of  bloody 
ascitic  fluid  withdrawn.     She  died  on  the  following  day. 

Autopsy  showed  thai  the  kidneys  were  noi'niai.  The  alxloniinal  timior  was 
apparently  a  sarcoma  of  the  lixcr,  two  large  nodules  being  found,  one  in  the 
right,  the  othei'  in  the  left,  lobe.  There  wci'e  genei-;il  niet.Mslnses  ihi'oughout 
the  abdomen. 

l^ath.  No.  S72.').  The  specimen  consists  ol'  the  body  of  I  he  uterus,  |);irl  of  the 
right  tul)e,  and  of  large  myomatous  masses.  The  specimen  is  dJNided  into  two 
masses,  connectecl  by  a  twisted  pedicle.  I  cm.  in  diameter.  The  sniallei'  mass 
consists  of  the  much  distoi'ted  bod\'of  l  he  uteinis.  w  ith  t  hi-ee  m\-omatous  nodules. 


202 


:\IY()MATA    O?"   THK    UTERUS. 


The  Upper  and  lart^cr  mass  is  composod  of  one  large  heart-shaped  tumor  that 
measures  21    x  22  cm.     The  U))i)er  mass  is  yellowish-white  in  color  and  has 


Fig.  135. — Sarcoma  D?;veloping  in  the  Center  of  a  Subperitoneal  Myoma.  (|  nat.  size.) 
Gyn.  No.  12155.  Path.  No.  8723.  At  the  time  of  operation  sarcoma  was  not  suspected.  This  is  a  cross- 
section  of  a  flattened,  subperitoneal  myoma.  The  outer  zone  consists  of  typical  myomatous  tissue,  but  the  central 
portion  has  undergone  degeneration.  The  line  of  demarcation  is  sharply  defined,  as  seen  at  a.  At  b  the  tissue 
is  homogeneous  and  shows  some  disintegration.  At  this  point  there  is  also  calcification.  A  cystic  space  is  seen  at 
c,  and  in  the  area  indicated  by  d  the  tissue  has  comjjletely  lost  its  muscular  striation  and  has  been  converted  into 
a  characteristic  homogeneous  sarcomatous  growth.  As  can  be  gathered  from  the  history,  the  sarcoma  was  of 
a  most  virulent  type. 


numerous  bright-red  injecled  areas.     Attached  to  the  surface  are  omental  ad- 
hesions over  an  area  10  cm.  across.     The  omentum  is  here  densely  adherent; 


MYOSARCOMA    OF   THE   UTERUS.  203 

it  iy  iiitimatclv  hlciulcd  with  the  tumor,  and  has  ('vi(h'ntly  furnished  it  a  hberal 
blood-sii])i)lv.  The  uterus  is  greatly  distorted,  and  the  normal  tissue  every- 
where has  been  replaced  by  a  myomatous  growth.  The  anterior  uterine  wall 
appears  to  be  of  normal  thickness.  The  uterine  cavity  is  enlarged  and  stretched. 
It  is  8  cm.  in  length  and  4  cm.  broad.  From  the  upper  inner  and  anterior  wall 
of  the  uterus  projects  a  tumor  showing  polypoid  masses  that  are  smooth  and 
very  soft.  Projecting  into  the  cavity  from  the  fundus  is  a  polyp  5  cm.  in  length, 
3  cm.  in  breadth,  and  tapering  dovm.  to  1  cm.  at  the  point.  It  resembles  veiy 
much  a  chicken's  liver.  It  is  long,  narrow,  and  spongy,  and  apparently  consists  of 
mucosa.  On  section,  the  large  myoma  shows  in  the  center  an  oval  area  9  cm. 
in  length  and  7  cm.  in  breadth.  It  is  sharply  circumscribed,  yellowish  or  whitish- 
yellow,  reddish,  or  brownish  in  color,  and  presents  a  very  mottled  appearance. 
In  many  places  it  is  homogeneous.  In  some  places  it  looks  friable  (Fig.  135). 
At  numerous  points  the  blood-vessels  are  injected  and  reach  1  mm.  or  more 
in  diameter.  The  picture  macroscopically  is  most  suggestive  of  sarcoma.  It 
was  not  until  after  the  patient's  death  that  this  portion  of  the  tumor  was 
examined,  otherwise  a  definite  clue  to  the  subsequent  clinical  history  would  have 
been  obtainable. 

On  histologic  examination  the  nuicosa  shows  considerable  disintegration, 
but,  taken  on  the  whole,  apart  from  some  dilatation  of  the  glands,  it  is  perfectly 
normal.  Sections  from  the  uterine  muscle  show  nuich  hyaline  degeneration. 
Many  sections  were  made  from  the  suspicious  looking  areas  in  the  myoma.  .  In 
the  outlying  portions  is  typical,  but  somewhat  dense,  myomatous  tissue.  We  then 
come  upon  a  zone  where  there  is  almost  complete  death  or  hyaline  degeneration. 
Then  we  encounter  a  growth  not  so  rich  in  cells.  In  some  places  this  growth  is 
somewhat  homogeneous  in  character.  In  other  ])laces  it  a})pears  to  bear  a 
definite  relation  to  the  blood-vessels.  The  luiclei  of'the  cells  in  many  places  are 
of  the  natural  size.  At  other  points  they  are  somewhat  swollen  and  are  vesicular. 
Then  we  have  large  rounded  or  oval  cells  with  masses  of  chromatin,  irregular  in 
form,  and  showing  that  llir  nuclear  division  has  not  been  of  the  iioniial  type. 
At  other  points  we  ha\'e  elongated  cells  with  deeply  staining  luiclei.  Then  again 
the  cells  contain  two  or  three  miclei.  In  .some  jjlaces  tlie  bundles  of  nuiscle- 
fibers  are  still  preserved,  but  even  here  in  the  bundles  are  large  and  small  nuclei. 
At  some  points  nuclear  figures  are  to  be  made  out.  and  their  jticsence  in  the 
specimen  that  has  been  hardened  rather  slowly  certainly  indicates  that  the  growth 
has  been  an  active  one.  I'Acrywhere  we  have  cells  with  small  round  nuclei. 
These  apjx'ar  to  be  chiefly  nmscle-fibers.  They  haxc  been  cut  transversely, 
and  in  any  field  it  is  easy  to  find  several  of  the  veiT  large,  irregular  nuclei.  Soin(> 
portions  of  the  growth  show  coagulation  necrosis  oxer  large  nicas.  \\  lieic  the 
myoma  has  undergone  almost  coniplete  li(|uefaction  it  is  |»articulaily  interesting. 
as  here  the  cells  are  se])arated  from  one  another  by  (|uile  an  inter\al.  At  such 
j)()ints  large,  irr(>gularly  formed  nuclei  are  clearly  in  exideiice.  ()ther  portions 
of  the  growth  show  the  typical  appeai'ance  of  a  s])indle-celle(l  sarcoma.     Some 


204  .MVOMATA    OF    THK    ITIsltUS. 

of  the  1)1()(kI-V('ssc1s  arc  throiuboscd,  others  arc  pcrt'cctly  ])rcsci-vcd.     In  certain 

sections  wiicrc  there  is  coagiihition  necrosis  wc  have  marked  dihitation  of  the 

l)lood-vessels  and  hemorrhage  into  the  .surrounchng  tissue.     In  such  areas  there 

is  some  ])reservation  of  the  cell  elements  around  the  blood-vessels,  giving  the 

apjH'arance  of  an  angiosarcoma. 

\\'e  have  in  this  case  a  sarcoma  developing  in  the  interior  of  a  very  large 

mvoma.  which  is  undergoing  hyaline  transformation.     The  sarcoma  is  of  the 

spindle-celled  variety,  and  must  have  originated  from  the  muscle-fibers,  as  all 

transition  stages  can  be  followed.     From  the  histologic  standpoint  there  is  no 

doubt  as  to  the  ])()sitive  diagnosis  of  sarcoma  with  accompanying  degeneration. 

After  making  this  diagnosis  w(>  learned  that  the  ]iatient  shortly  after  developed 

metastases  and  died. 

San.  No.  1879.     Path.  No.  8458. 

S  a  1-  c  o  m  a  t  o  u  s  t  r  a  n  s  f  o  r  m  a  t  i  o  n  in  t  h  e  interstitial 
p  o  r  t  i  0  n    0  f   a   s  u  b  m  u  c  o  u  s  m  y  o  m  a     (  F  i  g  .    1  3  6  )  . 

F.  D.,  white,  aged  forty-one,  mai-ried.  Admitted  March  26;  discharged 
May  5,  1905.  The  patient  has  been  married  fifteen  years  and  has  had  one  child, 
but  no  miscarriages.  Her  menses  have  been  excessive  and  accom])anied  by 
some  pain.  At  times  there  has  been  a  ])i'ofuse  vaginal  discharge.  Her  family 
and  j)revious  history  are  negative.  She  has  lost  no  weight.  For  the  last  few 
months  she  has  suffered  from  an  excessive  flow,  at  times  amounting  almost  to 
Hooding.  There  has  always  been  })ressure  on  the  bladder  and  rectum,  and  a 
bearing-down  sensation  in  the  lower  abdomen.  (\)ni])lete  hysterectomy  was 
performed,  and  the  ))atient  made  a  satisfactory  recovery. 

Path.  No.  S4r>S.  The  s))ecimen  consists  of  a  uterus  which  has  been  com- 
pletely removed.  It  is  12  cm.  in  length,  8  cm.  in  bn^adth,  and  8  cm.  in  its  antero- 
posterior diameter.  Attached  to  it  are  the  tubes  and  ovaries.  The  uterus  has 
a  smooth  peritoneal  covering.  Projecting  from  the  posterior  surface  are  two 
small  myomatous  nodules,  the  larger  of  which  is  1  cm.  in  diameter.  Where  the 
uterine  cavity  has  been  opened  it  is  o  cm.  in  length.  The  mucosa  of  the  posterior 
wall  is  2  or  'A  mm.  in  thickness.  That  of  the  anterior  wall  is  exceedingly  thin, 
owhig  to  the  presence  of  a  growth  which  occupies  the  entire  body  and  projects 
into  the  uterine  cavity.  This  growth,  on  section,  is  found  to  \m  somewhat 
irregular  and  reaches  (>  cm.  in  length.  The  lower  portion,  where  it  ])rojects  into 
the  ca\'ity,  consists  of  tyj)ical  myomatous  tissue,  but  in  the  upper  portion  this 
gradually  shades  over  into  a  growth  that  is  smooth,  whitish-yellow  in  a))])earance, 
and  homogeneous  (Fig.  136).  One  is  instantly  i-eminded  of  .sarcoma.  Further 
sections  of  the  tumor  leave  fit  tie  doubt  that  it  is  a  malignant  growth,  and  in 
addition  this  nodule  gradually  slunles  over  into  myomatous  tissue.  This  can  be 
readily  determined  macroscopically.  On  retracing  our  ste))s  to  the  myomatous 
tissue  we  find  that,  in  places,  it  has  undergone  a  certain  amount  of  ]i(iue- 
faction,  characteristic  of  that  a.ssociated  with  hyaline  transformation.  The 
tubes  and  ovaries  on  both  sides  appear  to  be  normal. 


MYOSARCOMA    OF    THE    UTERUS. 


205 


Histologic  Examination. — Sections  from  tlic  endometrium  show  that  the 
mucosa  has  an  intact  surface  ei)itheHum.  The  glands  look  perfectly  normal. 
The  mucosa  in  the  wall  over  the  submucous  nodule  is  nnich  atro])hied.  The 
surface  epithelium  is  still  intact,  but  the  glands  are  to  a  great  extent  missing, 
and  we  have  spaces  containing  nothing  but  coagulated  serum.  They  appear  to 
be  dilated  lymphatic  channels. 

The  lower  })art  of  the  growth,  which  macroscopically  resembled  a  myoma, 
consists  essentially  of  myomatous  tissue  which  here  and  there  has  imdergone  a 
certain  amount  of  liquefaction.  As  one  passes  into  tlie  depth  the  nuiscle- 
fibers  are  more  closely  packed  together.     They  vary  considerably  in  shape  and 

size.  A  short  distance  farther 
on  we  have  a  typical  sarcomat- 
ous growth.  In  this  growth  the 
cells  are  very  closely  packed  to- 
gether.   There  are  large  areas  of 


Fig.  136. — Sarcoma  Dkvki.opinc.  in  Part,  at  I.kast,  irom  a  Submucous  Myoma.  (5  nat.  size.) 
San.  No.  1879.  Path.  No.  8458.  The  section  represents  the  anterior  half  of  the  uterus.  The  cervix  is 
normal.  In  one  uterine  wall  are  two  small  niyomata.  Projecting  into  the  uterine  cavity  is  a  submucous  myoma. 
In  the  lower  i)art  this  presents  the  typical  striated  appearance,  but  in  its  upper  portion  it  Rradually  shades  off 
into  a  homogeneous  growth — typical  sarcomatous  tissue.  Macroscopically,  the  gradual  merging  of  the  myoma 
into  the  sarcoma  could  be  traced.  The  histologic  cxainiiiation  also  ciemonstrate<l  the  transformation  of  muscle- 
fibers  into  sarcoma  cells. 


cells,  with  here  and  there  large  oi-  small  blood-vessels.  Here  and  ihei-e  nurl(>ar 
figures  are  demonstrable.  The  growth  is  a  spiiKJIc-cclJcd  sai'coiiia.  The  cells, 
on  the  whole,  ai'e  very  unifoi'm  in  size  and  do  nol  show  any  leiidcncx'  lo  form 
large  masses  of  chromatin.  The  transition  from  the  myoma  into  the  sai'coma 
and  the  contour  of  the  myoma  and  .sarcoma  wouhl  macro.scopically  lea\-e  little 
doubt  as  to  the  origin  of  the  sarcomatous  gi-owth,  e\('n  though  we  had  nol  the 
corroborative  evidence  as  funiished  by  the  microscope. 

December  21,  190():    "Mrs.  1).  has  \\i-itten  ivi»cal(Mily  that  she  is  in  the  best 
of  health"  (H.  A.  Kelly). 


206 


MYOMATA    OF   THE    UTERUS. 


This  case  had  been  overlooked  in  the  routine  histologic  examination.  The 
uterus  had  been  cut  partially  in  two,  and  the  section  had  gone  through  the 
lower  portion  of  the  myoma,  which  presented  the  typical  myomatous  appearance. 
It  was  only  when  we  made  a  section  entirely  through  the  uterus  that  this  growth, 
which  was  clrarly  sarcomatous,  even  macroscopically,  was  discovered. 

H.  A.  K.  San.  No.  1857.     Path.  No.  8349. 

C  o  m  m  e  n  c  i  n  g  s  a  r  c  o  111  a  in  an  i  n  t  r  a  1  i  g  a  111  e  n  t  a  r  y  m  y  - 
o  m  a   (Fig.  137). 

A.  L.,  white,  married,  aged  forty-six.  Admitted  March  8;  discharged 
April  16,  1905.     The  menstrual  history  has  been  normal,  except  for  an  offensive 


Fig.  137. — .■^.  Myom.\  Situated  to  tuk  Right  of  the  Cervix  and  Showing  E.\rly  SARcoMATors  Changes. 

(/j  nat.  size.) 
Path.  No.  8349.     The  section  represents  the  posterior  half  of  the  uterus.     Portions  of  the  uterine  cavity  and 
cervical  canal  are  seen.     The  myoma  to  the  right  of  the  cervix  macroscopically  presents  the  usual  appearance, 
but  on  histologic  examination  sarcomatous  transformation  of  muscle-fiber.s  was  ilemonstrable. 


flow.  Of  late  there  has  been  a  slight  leukorrhea.  The  ])atient  has  a  constant 
feeling  of  pressure  on  the  bladder  and  a  continuous  desire  to  urinate.  There  is 
some  bearing-doA\Ti  pain  in  the  rectum.     She  never  has  a  natural  movement. 

Operation  March  9,  1905.  Hysteromyomectomy.  The  patient  made  a  satis- 
factory recovery,  but  was  not  very  strong.  Her  highest  jiostoperative  tem])era- 
ture  was  101.2°. 

Path.  No.  8349.  The  s})ecimen  consists  of  the  uterus  and  of  a  growth  spring- 
ing from  the  right  side  of  the  cervix,  and  extending  into  the  broad  ligament. 
The  uterus  itself,  which  has  been  amputated  through  the  cervix,  measures  11  x 
9x8  cm.  Posteriorly,  it  is  covered  with  adhesions;  anteriorly,  it  is  smooth. 
The  uterine  walls  contain  several  myomata,  chiefly  interstitial.     The  largest  of 


MYOSARCOMA   OF   THE   UTERUS,  207 

these  is  2  cm.  in  diameter.  Attached  to  the  right  side  of  the  cervix  is  a  myoma, 
9x6x7  cm.  This  was  evidently  not  covered  with  peritoneum,  and  extended 
out  into  the  right  broad  ligament.  The  right  tube  looks  normal.  The  left  tube 
and  ovary  are  normal.  On  section,  the  large  nodule  to  the  right  of  the  cervix 
resembles  an  ordinary  myoma  (Fig.  137),  although  at  first  sight  its  lobulated 
appearance  suggests  a  malignant  growth. 

Histologic  Examination. — On  examination  of  the  large  myomatous  nodule 
one  instantly  sees  that  something  unusual  exists.  In  the  outlying  portion 
typical  myomatous  tissue  is  encountered.  Then,  with  the  low  power,  we  see 
that  there  is  a  decided  picture  of  unrest.  The  nmscle  nuclei  become  two  or 
three  times  the  natural  size.  Some  of  them  stain  palely,  others  intensely.  In 
the  individual  muscle-bundles  one  sees  an  increase  in  the  size  of  the  nuclei.  The 
change  is  limited  almost  entirely  to  the  muscle-fibers  themselves.  At  other 
points  we  have  deeply  staining  masses  of  chromatin  representing  nuclei.  At 
still  other  places  are  irregular  and  deeply  staining  nuclei.  The  proliferation  at 
certain  points  is  of  such  a  character  that  it  bears  a  slight  resemblance  to  gland 
formation,  or  might  suggest  that  these  large  cells  were  in  part  due  to  proliferation 
of  the  endothelium  of  the  capillaries.  In  other  places  we  find  the  protoi)lasm 
of  the  muscle-fibers  greatly  increased  in  size,  corresponding  with  the  increase  in 
size  of  the  nuclei.  In  some  sections  a  very  interesting  picture  is  to  be  noted. 
There  is  a  good  deal  of  edema  and  liquefaction  of  the  myoma,  and  in  such  areas 
we  find  the  nuclei  particularly  prone  to  increase  in  size  and  to  stain  deeply.  In 
those  areas  we  find  the  individual  cells  teased  out  from  one  another.  There  is  a 
marked  tendency  for  the  cells  still  remaining  to  swell  up,  and  for  the  deeply 
staining  nuclei  to  nmltiply  in  number. 

This  specimen  in  particular  leads  one  to  think  that  the  hj-aline  degeneration 
and  the  liquefaction  of  myomata  are  factors  predisposing  to  the  development  of 
sarcomatous  growths.  Several  of  our  cases  have  emphasized  this  point,  and  it 
is  particularly  well  illustrated  in  Fig.  148  (p.  225). 

In  other  places  the  cells  are  diminishing  in  nuinhci-.  In  the  sections  in 
which  they  still  persist  they  lie  far  apart.  They  have,  therefore,  an  increased 
stimulus  to  active  division.  Sections  from  other  portions  of  the  growth  show 
that,  in  certain  areas,  these  large  active  cells  are  found  in  groups  or  colonies. 

Although  the  myoma,  as  noted  macr()S('()|)ically,  is  not  very  large,  we  haNc 
undoubted  evidence  of  commencing  sarcomatous  transformation.  Inasmuch  as 
in  none  of  the  sections  do  \vi\  find  these  cells  I'ight  out  at  the  margin,  the  prog- 
nosis Tnight  not  be  uiifa\'oi"able.  Thei'e  is  little  doubt,  howevei",  that  had  this 
process  gone  nmch  farther,  metastases  would  ha\-e  taken  place.  Sections  I'loiii 
the  cervix  show  perfectly  a  normal  cervical  mucosa.  The  endomc^trium  in  the 
depth  has  been  poorly  ])reserved,  but  looks  noi-mal. 

In  a  letter  dated  .lamiaiy  2*.),  1!)()7,  Dr.  Doiiehoo  reports  that  the  patient  is 
in  excellent  health. 


208  MVoMATA    OF    THK    UTPmUS. 

Gyn.  No.  7474.     Path.  No.  3729. 

S  a  r  c  o  111  a  d  c  v  c  1  o  j)  i  11  ^  in  t  h  e  cent  c  r  o  f  a  la  r  g  0  u  t  e  r  - 
i  n  V  111  y  0  111  a     (  Figs.    1  3  S  a  11  d   189). 

T.  B.,  white,  aged  fifty-two.  married.  Admitted  January  1 :  died  February  5, 
1000.  ("(iiiiplaint.  abdominal  lunioi-.  The  patient  has  been  married  thirty-hve 
years  and  has  had  .seven  ehildreii,  but  no  miscarriages.  The  eldest  child  is 
thirty-five  year.s  of  age.  Her  j)eriods  commenced  at  fourteen,  were  regular, 
lasting  from  six  to  seven  days,  and  not  \'erv  jirofuse.  About  five  years  ago  the 
periods  became  less  freciuent,  and  last  year  they  cea.sed  entirely.  The  tumor 
was  first  noticed  about  twelve  years  ago.  The  abdomen  is  now  filled  with  a 
tumor  which  extends  down  into  the  pelvis.  It  reaches  14  cm.  to  the  right  of 
the  median  line,  and  fills  the  entire  left  .side  of  the  alxlomen.  Hounded  masses 
as  large  as  tenni.s-balls  can  be  felt  connected  with  the  main  tumor.  These  are 
softer,  especially  at  the  costal  margin  on  the  left  side. 

On  vaginal  examinatic^n  the  outlet  is  considerably  relaxed.  There  is  a 
slight  bulging  of  both  anterior  and  posterior  walls.  There  is  also  a  slight  bluish 
discoloration  of  the  mucosa.  The  cervix  is  pushed  up  behind  the  symphysis,  but 
is  of  normal  size  and  consistence.  The  external  os  admits  the  tip  of  the  index- 
finger. 

Operation,  January  8, 1900,  supravaginal  hysteromyomectomy.  On  section  of 
the  abdomen  a  large  white  n(>crotic  patch,  fully  15  cm.  in  diameter,  was  found 
on  the  front  of  the  tumor.  Coursing  over  the  sides  of  the  tumor  were  large 
congeries  of  blood-vessels.  The  uterine  arteries  were  fully  as  large  as  normal 
femoral  arteries,  and  pursued  a  tortuous  course  over  the  surface  of  the  tumor. 
On  account  of  the  difficulty  in  getting  at  the  vessels  the  uterus  was  bisected. 
The  tumor  was  shelled  out.  after  which  the  collapsed  organ  was  easily  removed. 

January  27th :  The  malignant  character  of  the  growth  having  been  established, 
it  was  decided  to  excise  the  cervical  stump.  The  cervix  was  grasped  with 
tenaculum  forceps  and  drawn  forcibly  downward.  There  was  considerable 
oozing,  which  was  checked  by  the  fi'ee  use  of  catgut  .sutures.  The  removal  of 
the  cervix  was  fraught  with  considerable  difficulty.  Th(>  anterior  and  posterior 
vaginal  walls  were  a])pr()xiinate(l  in  the  median  line  with  two  .sutures,  and  a 
gauze  drain  was  inti'odueed  to  the  right  and  left  side. 

Feljruary  5th:  The  patient  gradually  developed  signs  of  intestinal  adhesions, 
requiring  an  exploratory  operation.  A  median  incision  was  made.  Loops  of 
small  intestine  were  found  adherent  along  the  line  of  incision.  These  wen; 
freed,  but  with  some  difficulty.  The  omentum  was  adhei'ent  to  the  .scar,  and 
also  to  the  intestines.  It  was  ligated  and  cut  awa3\  The  small  intestines  were 
quite  distended,  and  in  the  pelvis  the  intestinal  coils  were  flaccid.  There  did  not 
appear  to  be  any  peritonitis,  and  no  fibrin  was  seen  on  the  loops  of  gut.  The 
intestinal  loops  were  adherent  to  one  another,  to  the  bladder,  the  broad  ligament, 
and  the  site  of  the  drain  in  the  pelvic  floor.  These  adhesions  were  separated,  at 
times  with  the  finger,  but  in  some  places  were  so  den.se  that  scissors  and  knife 


MYOSARCOMA    OF   THE    ITKHUS. 


209 


Fk;.  138. — Sarcoma  Dkvki.opixc    in  tiik  Ckntkii  of  a  Fauck  Intkustitiai,  Ui-i;ki\i;  Myoma.     (|  nat.  size.) 

Path.  No.  3729.  The  picture  represents  the  cut  surface  of  a  longitudinal  section  throuKh  a  greatly  enlarKetl 
uterus,  a  is  the  posterior  uterine  wall,  which,  consideriiiK  the  stretching  of  the  walls,  is  of  the  usual  thickne.ss. 
b  is  the  uterine  cavity  which  has  been  greatly  lengthened  out.  Had  a  uterinesouiid  been  pa,ssed,  it  would  scarcely 
have  reached  the  top  of  the  cavity.  The  uterine  mucosa  is  scarcely  1  mm.  in  thickne.ss.  Occupying  the  anterior 
wall  is  a  large  interstitial  myoma,  very  sharply  ddiiicd  fnun  the  muscle.  .\t  several  points,  especially  at  c  and 
d,  are  very  dense  myomatous  foci,  easily  recognizeil  liy  their  lighter  hue.  ."scattered  througlmut  tlie  large  myoma 
are  large  and  small  sarcomatous  masses.  The  sarcomatous  growth  le)  is  one  of  .several  small  ones.  .Ml  are  homo- 
geneous in  structure  and  sharply  outlined  from  the  mu.scular  growth.  In  the  sarcomatous  noilule  cfHs  an  irregular 
cystic  cavity.  The  nodule  (g)  shows  areas  varying  in  color  and  consistence.  This  is  due  to  a  breaking-ilown  of  the 
malignant  growth.  The  largest  sarcomatous;  focus  (h)  has  undergone  almost  complete  necrosis,  a.s  is  indicated  by 
the  lighter  central  portion,  only  a  small  outer  rim  of  solid  tissue  remaining.  The  variovis  clefts  in  the  center  of  this 
nodule  are  due  to  the  degenerative  process,  i  indicates  a  sarcomatous  nodule  situated  in  the  cervix  near  the 
internal  os.  In  this  ca.se  the  growth  was  iirimary  in  the  myoma,  showing  conclusively  that  it  developed  from  the 
myomatous  tissue.  Sarcoma  was  not  suspecte<i  until  the  specimen  reached  the  laboratory.  This  case  indicates 
clearly  the  advisability  of  opening  the  uterus  at  once  after  removal.  If  the  malignant  jirocess  be  present,  the 
cervix   can  then   be   removed    before  the   abdomen    is   closed,  thus   saving   the    patient    a    secoml    oi)eration,    an<l 

avoiding  the  danger  of  leaving  a  possible  sarcomatous  cervix  for  a  pciidd  nf  t\v •  three  weeks  hmger.     The  large 

myoma  was  shelled  out  of  the  uterus  with  ease. 
14 


210  MVo.MATA    OK    THK    ITKRl'S. 

were  RHiuired.  At  the  \nnut  at  which  constriction  had  taken  ])lacc  the  adhesions 
were  extremely  dense,  and  over  an  area  two  inches  in  leno;th,  and  ahnost  sni- 
rounding  the  circumference  of  the  intestine,  the  peritoneum  had  been  denuded 
and  some  of  the  muscle-fibers  were  wanting.*  A  small  rent,  1.5  cm.  long,  was 
made  in  the  lumen  of  the  gut.  This  was  brought  out  at  the  side,  most  of  the 
fecal  matter  and  gas  above  was  forced  out,  and  the  tear  in  the  collapsed  in- 
testine was  then  closed  with  three  mattress  silk  suturesand  an  additional  layer  of 
Lembert  sutures.  All  adhesions  were  separated  except  over  a  small  area  of  the 
sigmoid.  The  sutures  and  denuded  areas  were  placed  low  down  in  the  abdo- 
men, next  to  the  gauze  drain,  which  was  packed  in  the  pelvis.  This  loop  at  the 
point  of  stricture  was  straightened  out  so  as  to  prevent  reformation  of  the  stric- 
ture. The  pulse  was  weak,  and  respiration  rapid.  The  patient  failed  to  react 
to  stimulation,  and  died  on  the  following  day. 

I'ath.  Xo.  3729.  The  specinu^n  consists  of  a  large  myoma  which  has  been 
shelled  out.  and  also  of  the  uterus  with  the  attached  tubes  and  ovaries.  The 
tumor  is  ai)proxiiiiately  gIol)ular,  b(>ing  20  x  20  x  IS  cm.  in  its  various  diameters. 
In  part  it  is  smooth  and  glistening  and  covered  with  peritoneum.  At  least 
three-quarters  of  it,  however,  has  a  ragged  appearance,  owing  to  the  presence  of  a 
large  myoma,  Avhich  has  at  least  two  lobulations  due  to  clefts  extending  from  3 
to  ")  em.  into  tlie  de])th.  These  lobulations  are  further  sul)(li\-ided  l)y  minor 
clefts.  The  tumor,  as  a  whole,  is  firm,  Init  one  of  the  lobulated  areas  is  rather 
soft.  On  section,  the  tumor  is  found  to  consist  of  two  distinct  elements,  the 
outer  enveloping  portion  made  up  of  muscle  and  a  central  i)ortion  consisting  of 
a  soft  growth  (Fig.  138).  This  is  yellow  in  color,  does  not  show  the  striation 
of  muscle,  but  presents  a  porous  appearance  and,  in  fact,  might  be  likened  to 
a  very  fine  sponge.  The  central  portion  of  this  growth  is  slightly  friable,  and  here 
the  ])orous  a])pearance  is  more  pronounced.  It  also  shows  numerous  clefts.  This 
large  new-growth  makes  up  fully  one-half  of  the  myoma,  and  other  similar  but 
smaller  nodules,  varying  from  1  to  7  cm.  in  diameter,  stud  the  outlying  portion. 
One  of  the  largest  lobulations  noted  on  the  outer  surface  consists  essentially  of  this 
peculiar  new-growth,  and  here  marked  softening  has  taken  place.  In  the  cervix  is 
a  nodule,  4  cm.  in  length,  3.5  cm.  in  breadth,  and  1  cm.  in  thickness.  It  is  at- 
tached by  a  pedicle  2  cm.  broad.  The  nodule  is  ))(M-fectly  smooth  and  has  an 
intact  surface.  The  uterine  cavity  is  13.5  cm.  long  and  11  em.  broad  at  the 
fundus.  The  surface  of  the  mucosa  has  a  pinkish-yellow  color  and  is  somewhat 
wrinkled  in  appearance.  Al)out  the  middle  of  the  right  lateral  wall  is  a  disc- 
like projection,  raised  1.5  mm.  above  the  mucosa.  Its  margins  are  sharply 
defined.     At  the  fundus  is  a  soft  ])olyp,  2  cm.  in  diameter. 

The  right  tube  is  15  cm.  long  and  fi'ee  fi-oiii  adhesions.  The  ovary  is  greatly 
flattened  and  measures  6  x  2  x  0.5  cm. 

The  left  tube  is  11  cm.  long.  The  ovary  has  the  .same  dimensions  as  that  of 
the  opposite  side,  and  is  free  from  adhesions. 

*\Vith  our  present  knowledge  we  would,  of  course,  merely  do  an  enterostomy. 


MYOSARCOMA    OF    THE    ITKRUS. 


211 


9 


*  ^d 


'«, 


« 


1$  • 


Histologic  Exaiiiinatioii. — The  large  tumor  that  was  shelled  out  from  the 
uterus  consists  of  non-striped  muscle-fibers  cut  in  various  directions,  and  pre- 
senting the  usual  appearance  of  myoma.  Here  and  there  is  much  hyaline  de- 
generation, principally  diffuse  in  character.  The  large  porous  tumor,  occupymg 
the  center  of  the  myoma,  and  diff'ering  from  it  so  widely  macroscopically,  shows 
a  still  greater  contrast  on  histologic  examination.  It  consists  of  a  sea  of  cells 
all  having  the  same  genei-al 
characteristics.  Its  tissue  is 
traversed  in  all  directions  by 
the  most  delicate  capillaries, 
consisting  merely  of  an  endo- 
thelial lining.  The  cells  of 
the  growth  are  round  and 
have  round,  uniformly  deeply 
staining  nuclei  (Fig.  139). 
They  vary  greatly  in  size,  and 
all  gradations  from  minute 
spheric  nuclei  to  those  ten  or 
twelve  times  larger  are  clearly 
demonstrable.  It  looks  very 
nuich  as  if  the  small  cells 
were  gradually  developing 
into  the  larger  ones.  Some  of 
the  large  nuclei  are  irregular 
in  outline  and  contain  pale- 
staining  spheric  dropk^ts. 
Between    the   cells  w(»  occa- 


\^ 


^^^J^g.% 


«P 


©  ©  o  *  ^ 


< 


9  4 


Fig.  139. — Sarcoma    Developing  in  the   Interior  of  a  Myoma. 
(X  360  diam.) 
Path.  No.  3729.     The  section  is  taken  from  the  sarcoma  seen 
in  Fig.  138.     The  deUcate-walled  blood  capiUary  (a)  divides  the  fiehi 
into  an  upper  half,  composed  of  large  cells,  and  a  lower,  of  much 
smaller  cells.     The  cells  are  loosely  arranged.     In  most  places  it  is 
Sionally        see        large        blood-        jmssible  to  clearly  outline  not  only  the  nucleus,  but  its  protoplasm. 

In  the  upper  half  of  the  field,  b  may  be  taken  to  represent  the  aver- 
age size  of  the  cell.  These  nuclei  and  those  indicateil  by  c  are  mod- 
erately enlarged  and  irregular  and  stain  more  deeply.  At  d  we  have 
a  relatively  much  larger  cell,  and  at  e  the  nucleus  of  a  cell  is  divided 
into  two,  while  a.s  yet  no  cleavage  has  occurred  in  the  protoplasm. 
In  the  lower  half  of  the  field  the  cells  iire  fairly  uniform.  At  f 
a  small  cell  contains  two  nuclei,  anil  at  g  is  a  l)udding  nucleus.  Froni 
a  careful  study  of  many  sections  we  gather  the  impression  that  the 
cells  were  at  first  very  small,  ami  that  they  have  gradually  devel- 
oped into  the  large  ones,  'riiis  would  account  for  the  crops  of  small 
and  large  cells  foutid  side  by  side  and  yet  sharply  defiiieil  from  one 
another. 

numerous    points    tiiere    has 

evidently  been  an  old  hemorrhage,  as  the  tissue  is  studded  with  l»ro\\n  pigment- 
granules.  The  growth  is  a  round-celled  sarcoma.  The  other  porous  nodules 
scattered  throughout  the  myoma  are  also  sai'comatous  in  origin.  Scattered 
throughout  various  |)ortioiis  of  the  mycuiia  .■we  microsco])ic  loci  of  sarcomatous 
tissue. 

The  uterine  mucosa  is  much  atrophie(l,  bui   its  sui'face  e|)ithelium  is  intact. 
The  glands  ai'e  ati"o])hic,  and  in  a  Few  places  ai)iiarently  dilated.     The  stroma 


vessels,  with  practically  no 
connective-tissue  framewoi'k. 
Many  areas  show  hemorrhage, 
and  at  certain  points  there 
is  complete  coagulation  nec- 
rosis, often  accom])anied  by 
fragmentation  of  nuclei.     .\t 


212  MVOMATA    OF   THK    UTERUS. 

of  the  iiuicosa  consists  of  spiiullc-shujx'd  cells,  and  hciv  and  there  shows  some 
sinall-round-celled  infiltration.  The  large  nodule  in  the  cervical  canal  is  .sar- 
comatous, as  are  also  the  polyj)i  in  the  body.  The  smaller  polyp  in  the  body  has 
pushed  the  surface  epithelium  in  front  of  it.  This  is  well  ]-ecoo;nized  as  a  single 
row  of  cul)oid  cells  lying  directly  on  the  .-sarcomatous  tissue.  The  di.sc-like 
nodule  described  in  the  cavity  is  a  .small  submucous  myoma. 

In  this  most  instructive  ca.se  we  have  a  large  myoma,  partially  subperitoneal, 
but  to  a  great  extent  interstitial.  In  the  center  of  this  a  sarcoma  has  develoixnl, 
and  has  gradually  gi\'en  rise  to  secondary  foci  in  the  niNoma,  and  also  to  deposits 
in  the  uterine  wall  and  in  the  cavity  of  the  uterus.  That  the  growth  is  primarily 
of  myomatous  origin  we  are  practically  .sure.  In  no  other  ]iart  of  the  body  was 
there  a  primary  malignant  focus,  and  it  is  most  exceptional  to  find  a  metastasis 
in  a  m\'oma.     The  appendages  are  normal. 

This  case  demonstrates  very  clearly  the  advisability  of  avoiding  bisection  of 
the  uterus  whenever  sarcoma  is  suspected. 

Gyn,  Nos.  7040  and  7212.     Path.  Nos.  3312  and  3472. 

Subperitoneal,  interstitial,  a  n  d  s  u  b  m  u  c  o  u  s  u  t  e  r  - 
i  n  e  m  y  o  m  a  t  a  ;  large  c  i  r  c  u  m  s  c  r  i  1 )  e  d  s  a  r  c  o  m  a  tons  nod- 
ule in  the  u  t  e  r  u  s ,  a  p  p  a  r  e  n  t 1 y  originating  in  a 
myoma  (Figs.  140,  141);  atrophy  of  t  h  e  u  t  e  r  i  n  e  m  u  - 
c  o  s  a  :  nor  m  a  1  a  }>  \)  e  n  d  a  g  e  s  .  S  u  p  r  a  v  a  g  i  n  a  1  h  y  s  t  e  r  e  c  - 
t  o  m  y  w  i  t  h   ret  u  r  n   o  f    t  h  e  growth  in   t  h  e  c  e  r  v  i  x  . 

E.  C.  H.,  white,  married,  aged  fifty.  Admitted  July  2;  discharged  July 
28,  1899.  Complaint,  abdominal  tumor.  The  patient  has  had  two  children 
and  one  miscarriage.  The  first  lal)or  was  normal;  the  .second  was  attended 
with  a  great  deal  of  Hooding.  Her  menses  commenced  at  fourteen  and  were 
regular  until  two  years  ago,  lasting  from  five  to  six  days.  During  the  past  two 
years  the  flow  has  increased  in  amount,  has  been  dark  and  clotted,  and  has 
lasted  from  one  to  three  Aveeks. 

The  presence  of  a  tumor  was  first  susp(>cted  four  years  ago.  It  was  .slow  in 
growth  until  six  months  ago.  Since  that  time  it  has  increased  rajndly  in  size. 
The  bowels  have  l)een  regular,  and  there  has  l)een  a  fre([uent  desire  to  micturate. 
On  examination  the  outlet  is  found  to  be  markedly  relaxed.  The  cervix  is  low 
down.  Anteriorly,  the  entire  vaginal  vault  is  bulged  out  by  a  rounded,  .smooth, 
.somewhat  soft,  non-sensitive  mass.  This  is  wedged  down  in  the  jx'lvis,  is  im- 
mol)ile.  and  is  in  direct  connection  with  the  abdominal  nuiss,  which  extends  up- 
ward to  the  umbilicus.  The  right  fornix  is  clear,  exce))t  at  the  ajX'X.  where  the 
lateral  structures  are  palpable.     The  left  fornix  is  coni])letely  obliterated. 

Operation,  July  o.  IS'.M).  Hysteromyomectomy,  the  ut(>rus  being  aminitated 
through  the  cervix.  The  maximum  i)osto])erative  tem])eratvn-e  was  101.4°  F. 
The  patient  was  discharged  on  July  2Sth.  but  there  was  a  movable  mass  the  size 
of  a  walnut  on  the  right  side.  She  was  readmitted  to  the  hospital  .shortly  after- 
ward, and  died  September  25,  1899. 


MYOSARCO.MA    OF   THE    UTERUS. 


213 


Path.  No.  3312.  The  specimen  consists  of  an  enlar<2;ed  uterus,  tunimtated 
through  the  cervix,  and  of  the  ajipcndagcs.  The  uterus  presents  a  somewhat 
h)l)uhited  aj)peai'ance,  and  measures  15  x  13  x  11  cm.  At  a  few  points  there  are 
small  sul)peritoneal  nodules.  The  anterior  uterine  wall  is  fully  8  cm.  in  thick- 
nt^ss,  owing  to  its  invasion  by  a  new-growth.     Near  the  cervix  is  a  nodule  6  cm. 


Fig.  140. — Phohahi.i-;  Sarcomatous  Traxskohmatiox  of  a  Mvoma;  also  Discrkti:  Myom^tol's  and  Sarco- 
matous NoDui.ES  IN  THK  SAME  Uterus.     (i  nat.  size.) 

Path.  No.  .3312.  The  uterus,  which  is  much  enlarged,  has  been  opened  anteriorly.  Tlie  uterine  nuiscle,  aa 
ndicated  by  a,  is  much  thickened,  owing  to  a  general  hypertrophy.  At  b  is  a  small  myoma  which  hius  been  cut  in 
two.  c  is  one  of  many  large  and  small  areas  of  hDinogeneous  tissue  scattere<l  throughout  tlie  uterine  walls.  It  Is 
lighter  in  color  than  the  muscle,  and  is  shari)ly  imthned.  It  is  sarcomatous  tissue,  d  is  also  a  sarconuitous  nodule. 
It  contains  several  smooth  cystic  spaces,  a.s  indicated  l)y  e.  This  nodule  at  several  points  lacks  the  homogeneous 
appearance,  the  tissue  being  fibrillary  and  resembling  myoma.  This  is  ijarticularly  well  seen  at  f.  Here  we  have 
the  remnants  of  a  myoma  entirely  surrounded  by  sarcomatous  tissue.  Situateti  near  the  cervical  canal  is  a  small 
sarcomatous  nodule.  The  uterine  cavity  is  mvich  lengthetied.  Its  mucosa  is  atrophic,  and  situated  i\ear  the 
fundus  is  a  large,  slightly  lobulated  submucous  niyoma  (g).     Its  texture  is  readily  recognize*!  from  the  cut  surface. 

The  appearance  noted  in  the  nodule  d  suggests  that  in  this  particular  nodule  the  sarcoma  originate*.!  from 
the  my(jma. 

in  diameter,  irregular  in  contour,  and  consisting  in  part  of  myomatous  tissue. 
A  portion  of  it,  however,  has  lost  its  lihrillation ;  it  has  hccomi'  homogeneous  and 
is  yellowish  in  color.  This  area  is  very  suggestive  of  sarcoma,  and  on  section  is 
found  to  contain  irregulai',  cyst-like  spaces,  some  I'eaeliing  '2  em.  in  diameter 
(Figs.  140.  141).     The  t  hiekeiiing  in  the  anterior  wall  is  due  to  the  jiresenee  of  a 


214 


MVOMATA    OF    THH    ITKRUS. 


similar  ikkIuU-,  1)  x  ()  cm.  This  in  a  tVw  places  presents  a  myomatous  ])icture, 
hut  at  most  points  is  light  in  color,  homogeneous  in  consistence,  and  entirely 
devoid  of  fibrous  arrangement.  The  uterine  nmscle  shows  isolated  foci  of  this 
soft  growth.  On  section  of  the  large  nodule,  a  typical  myoma,  3  cm.  in  diameter, 
is  found  situated  in  the  center  of  this  peculiar  and  homogeneous  mass.  The 
l)osterior  uterine  wall  varies  from  o  to  T")  cm.  in  thickness,  the  increase  being 
due  to  the  ])resence  in  its  walls  of  a  sul)])eritoneal  and  partially  interstitial 
mvoma.      It    also  contains  a   few  small   foci   of   the  yellow  and   homogeneous 


I'k;.  141. — .\ssoci.'VTiON  of  Myoma  and  Saucoma  in  thi-:  hame  Uterus.     (,'1,  nat.  size.) 
Path.  No.  3312.     This  is  a  section  through  the  tliickened  uterine  wall  in  Fig.  140.     a  represents  the  coarse 
uterine  mii.scle,  which  forms  the  general  framework.     .\t  b  is  a  group  of  five  thin-walled  cysts.     At  c  and  c  are 
sections  of  two  myomata,  easily  recognized  by  their  striation.     At  d  is  one  of  the  many  smooth,  homogeneous, 
sarcomatous  nodules  scattered  throughout  the  uterine  wall. 

growth.  Situated  in  the  fundus  ai'e  several  of  these  small  growths;  projecting 
into  the  uterine  cavity  from  the  fundus  is  a  submucous  myoma,  7x4  cm. 

The  uterine  cavity  is  \'S  cm.  in  length.  Its  muco.sa  is  apparently  unaltered, 
and  has  nowhere  been  invaded  by  the  soft  and  homogeneous  growth.  ()v(>r  the 
submucous  myoma  the  mucosa  is  still  intact,  but  quite  atro])hic.  The  tubes 
and  ovaries  are  aj^parently  normal. 

Histologic  I'^xamination. — The  uterine  mucosa  is  considerably  atrophied. 
The  surface  epithelium  is  intact,  and  the  glands  present  the  normal  appearance. 


MYOSARCOMA    OF    THK    UTERUS.  215 

Over  the  subinucous  niyonia  it  is  possible  to  trace  the  surface  epithelium,  and 
here  and  there  a  group  of  glands  is  still  visible.  The  subnuicous  myoma  presents 
the  usual  appearance  and  shows  considerable  diffuse  hyaline  degeneration.  The 
soft  nodules  scattered  throughout  the  uterine  wall  consist  of  a  homogeneous 
tissue,  made  up  of  great  (juantities  of  cells,  in  most  places  showing  no  definite 
arrangement.  This  tissue  is  traversed  in  all  directions  by  delicate  blood  capil- 
laries. The  individual  cells  have  oval  or  round,  deeply  staining  nuclei,  and  here 
and  there  is  a  nucleus  five  or  six  times  the  size  of  its  neighbor,  and  staining  in- 
tensely with  hematoxylin.  These  cells  are  actively  growing.  Nuclear  figures 
are  abundant,  and  all  stages  of  karyokinesis  are  visible.  We  often  find  the 
chromatin  filaments  delaying  at  the  poles  instead  of  passing  along  the  achromatic 
threads  to  the  center.  Here  and  there  is  a  large  mass  of  protoplasm,  staining 
deeply  with  eosin,  antl  containing  several  deeply  staining  nuclei,  so  arranged  as  to 
form  a  mulberry-shaped  mass.  Large  portions  of  this  growth  have  undergone 
complete  coagulation  necrosis,  without  any  subsequent  polymorphonuclear 
infiltration.  In  some  places,  although  coagulation  necrosis  has  occurred,  the 
large  blood-vessels  in  such  areas  are  still  surrounded  by  a  zone  of  well-preserved 
sarcoma-cells.  The  line  of  demarcation  between  the  uterine  muscle  and  the 
new  growth  is  sharply  defined,  and  it  is  a  common  thing  to  see  the  sarcomatous 
cells  wandering  in  and  separating  the  muscle-fibers  from  one  another.  The 
growth  is  a  spindle-celled  sarcoma. 

In  this  case  we  have  an  enlarged  uterus  implicated  by  a  myomatous  and  at 
the  same  time  by  a  sarcomatous  process.  Macroscopically,  one  can  see  the 
gradual  merging  of  a  myoma  into  a  sarcoma,  and  in  a  large  nodule  a  typical 
myoma  is  surrounded  by  sarcomatous  tissue.  But  histologically  we  are  unable 
to  trace  the  transformation  of  myomatous  tissue  into  sarcomatous  tissue.  From 
the  general  arrangement,  however,  we  believe  that  the  sarcoma  developed  in  the 
myoma. 

The  Fallopian  tubes  are  normal.  The  right  ovary  contains  a  few  gland-like 
spaces  lined  with  cyliiKlric  cj)!! helium.  Both  ovaries  are,  however,  practically 
normal. 

Gyn.  No.  8732.     Path.  No.  4931. 

S  u  b  p  e  r  i  t  o  n  e  a  1  and  i  n  t  e  i-  s  t  i  t  i  a  1  u  t  e  r  i  n  c  m  y  o  ni  a  t  a  , 
m  i  X  e  d  -  c  e  1 1  e  d  s  a  r  c  o  m  a  o  f  t  h  e  a  n  t  e  r  i  o  r  u  t  c  r  i  n  c  w  all: 
w  i  t  h  r  e  m  n  a  n  t  s  of  the  in  y  o  in  a  in  its  i  n  t  c  r  i  o  r  (  !■'  i  g  s  . 
14  2,  143,  144).  Normal  cervical  in  u  c  o  s  a  :  at  r  o  p  h  y 
of    t  h  e  u  t  e  r  i  n  e   m  u  c  o  s  a  ;    n  o  r  in  a  1    a  p  p  e  n  d  a  g  e  s  . 

M.  J.  L.,  black,  married,  aged  forty-six.  Admitted  .Ma\-  •.):  died  May  1(), 
1901.  The  patient  had  one  miscarriage  two  years  ago.  Her  menses  began  at 
fifteen,  were  always  regular,  but  profuse,  and  lasted  from  tour  to  six  days.  The 
last  ])eriod  occurred  four  weeks  ago.  The  |)ntient"s  mind  is  not  ^■erv  clear,  and 
conse(iuently  a  coinj)lete  history  caimot  be  obtained.  The  cervix  is  in  the 
normal  position,  firmly  fixed.     Behind  it  is  a  large  hard  mass.     Situated  in  the 


2I(i 


MNd.MATA    (»l" 


ITKIUS. 


suix'rior  strait,  and  cxtciKliiiii'  up  into  the  alxldiiicii,  is  a  large  soft  mass,  the  size 
of  an  adult's  head. 

OjX'ration,  May  9th.  Panhysicrcctoiny.  The  largo  ma.ss  was  vory  soft  and 
Huc'tuating.  and  covered  with  vessels  ruiuiing  in  all  directions  beneath  the  peri- 
toneal surface.  Tile  tumor  in  the  hollow  of  the  sacrum  is  \-ei'v  hard.  As  the 
entile  growth  was  thought  to  he  myomatous,  enucleation  was  begun  with  the 
idea  of  cutting  across  the  cer\ix  and  then  t\"ing  the  left  ox^arian  vessels  and 
round  ligament,  and  hegiiminu'  t<>  work  down  to  the  left  uterine  \"essels.     A  slight 


Fio.  142. — -A  Sarcomatous  Uterus  Conformixg  in  CoxTorn  to  a  Globular  Myomatous  Uterus.  (,5  nat.  size.) 
Path.  No.  49.31.  The  uterus  is  much  enlarged,  globular  in  f<.im.  and  .«trongly  suggests  a  myomatou.s  con- 
dition, especially  a.s  the  majority  of  the  nodules  .seen  springing  from  the  posterior  surface  are  myomata.  The 
ikmIuIc  near  the  cervix  is  .seen  on  section  to  be  a  myoma,  and  the  dark  patches  scattered  throughout  it  are  areas 
of  calcification.  A  glance  at  Fig.  143  shows  that  the  greater  part  of  the  uterine  enlargement  is  due  to  the  presence 
of  a  .sarcoma  occu|)ying  the  anterior  wall. 

On  bimanual  examination  the  diagnosis  of  a  myomatous  uterus  would  naturally  be  the  most  rational  one, 
and  even  after  the  abdomen  was  f>pened,  there  would  be  little  to  suggest  sarcoma  except  the  rather  flabby  contour 
of  the  organ.  The  left  tube  and  both  ovaries  appear  to  be  normal.  The  right  tube  is  longer  than  usual.  .Situatetl 
between  the  left  tube  and  ovary  is  a  small  parovarian  cyst  (a). 


tear  in  the  lai'ge  t  uiiioi-  allowed  a  hi'ain-like  substance  to  ooze  out  o\'er  the  uterine 
vessels,  showing  almost  conclusi\-ely  that  the  large  growth  was  sarcomatous. 
Panhysterectomy  was  immediately  decided  upon.  The  large  vessels  were  tied 
ofT,  the  i)ladder  was  j)ushed  down,  and  the  vagina  incised  in  front  of  the  cervix, 
w  hich  was  <|uickly  cut  all  around.  The  entire  growth  and  the  pelvic  organs  were 
removed.  A  gauze  drain  was  placed  in  the  vagina.  After  operation  the  pulse 
gradually  became  rapid  and  the  patient  died  on  .May  Kith. 

Path.  No.  49.'U.     The  specimen  consists  of  an  enlarged  uterus  with  its  appen- 


.MVOSAHCD.MA    OF    THK    I'TKIU'S. 


217 


dages  intact.     The  uterus  (Fig.  142)  with  its  intact  cervix  is  a))|)n^xiniately  IS 
cm.  in  length,  lo  cm.  in  l)rea(hh,  and  15  cm.  in  its  anter()j)Osterior  diameter.     It 


Fu;.  14.3. — Sahcoma  and  Myo.ma  i.v  the  Samk  Uterus.  («  iiat.  size.) 
Path.  No.  4931.  This  is  an  anteroposterior  section  through  tlie  uterus  seen  in  F\k.  142.  a  is  the  upper  part 
of  the  uterine  cavity;  a'  is  that  of  the  cervical  portion.  The  walls  of  the  cervix  are  of  the  normal  thickness,  as 
seen  at  b.  The  uterine  mucosa  is  rather  atrojihic,  but  at  c  two  of  the  glands  show  cystic  dilatation.  Situateti  in 
the  posterior  wall  are  several  small,  ill-defined  myomata,  and  the  circuinscribe<l  nodule,  d.  The  dark  |)atche9  in 
the  myoma,  e,  are  areas  of  calcification.  This  is  the  myoma  seen  in  F'ig.  142.  Occupying  the  anterior  wall  of  the 
uterus  is  the  large  growth  f.  This  is  homogeneous  in  appearance  and  sharply  outline<l  from  the  uterine  muscle. 
It  is  partially  subdivided  into  smaller  ma,sses  by  septa  of  muscle.  At  g  are  the  remains  of  a  myoma  easily  recog- 
nized by  the  arrangement  of  the  muscle-bundles.  At  h  this  myoma  gradually  .shade.s  off  into  sarcomatous  tissue. 
Scattered  throughout  the  uterine  muscle  are  numerous  isolated  sarcomatous  foci,  as  seen  at  i.  It  looks  very  much 
as  if  the  myoma  (g)  had  undergone  sarcomatous  transformation.  If  the  sarcoma  ha<l  occurred  independently,  we 
would  expect  to  find  the  myoma  either  pushed  to  one  side  or  surrounded  by  sarcoma,  instead  of  merging  im- 
perceptibly into  it. 


is  irregular  and  nodular,  and  project ing  from  its  surface  are  se\-eral  peilunculaletl 
myomata,  the  largest  of  which  is  .">  cm.  in  diameter.     Situated  in  the  j)osteri()r 


218 


MYO.MATA    OF   THE    UTERUS. 


U .  Becker  w, 


e  "  d  k  c 

Fig.  144. — Mixed-cei.i.?:!)  Sahcoma  ok  tkk  Utkhus  .\ssoci.\tki)  with  Myomata  ov  the  Uterus.  (X  350  diam.) 
Path.  No.  4931.  The  .>iectii)ii  is  from  the  .sarcoma  in  Fig.  143.  At  first  glance  it  bears  some  resemblance  to 
chorio-epithelioina.  a  i.s  a  large  vein;  b  represents  the  average  size  of  the  nuclei.  At  numerous  points  indicated 
by  c  the  cells  are  greatly  enlarged;  they  stain  deeply,  and  their  chromatin  is  gathered  up  into  coarse  granules.  At 
.several  i)oitits,  d.  d,  the  large  nuclei  are  somewhat  constricted,  showing  a  tendency  toward  cleavage.  At  e  six 
nuclei  of  variable  size  are  contained  in  one  ma.ss  of  protojjlasm,  forming  a  giant-cell.  A  large  and  irregular  mass 
of  chromatin  with  several  projections  is  seen  at  f,  and  at  g  we  have  three  large  irregular  and  ragged  masses  of 
chromatin  contained  in  one  ma.ss  of  protoplasm.  Nearly  filling  the  large  vein  a  is  a  huge  plaque  of  protoplasm  (h) 
containing  many  large  and  small  irregular  masses  of  chromatin,  roughly  resembling  small  lumps  of  coal.  Scattered 
throughout  this  protopla.sm  are  many  small  round  cells  and  i>olymorphonuclear  leukocytes.  A  similar  mass  of 
protoplasm  (i)  fills  the  ui)per  jiart  of  the  vein.  1  represents  one  of  the  many  vacuoles  scattered  throughout  the 
field,  m  is  a  zone  of  stroma  which  forms  only  a  very  small  part  of  the  tumor.  It  is  impossible  to  determine  with 
certainty  whether  this  stroma  represents  connective  tissue  or  remnants  of  muscular  tissue. 


MYOSARCOMA    OF    THE    UTERUS.  219 

wall  is  an  interstitial  myoma,  fully  G  cm.  in  (liainctcr,  and  just  beneath  the 
peritoneum  of  the  anterior  wall  are  several  small,  soft,  and  slightly  raised  growths. 
These,  however,  are  in  no  way  suggestive  of  myomata.  The  chief  increase  in  size 
of  the  uterus  is  due  to  a  growth  fully  12  cm.  in  diameter,  occupying  the  anterior 
wall  (Fig.  143).  This  is  sharply  circvmiscribed,  yellowish-white,  translucent,  soft, 
edematous,  and  bears  a  striking  resemblance  to  the  gray  matter  of  the  brain. 
Scattered  throughout  it  are  bright  yellow  patches  and  others  of  a  greenish  hue. 
At  several  points  over  the  center  of  the  tumor  are  areas  slightly  suggestive  of 
myomatous  tissue.  The  large  tumor  has  an  outer  covei-ing  of  muscle  averaging 
2  mm.  in  thickness.  Its  inner  portion  extends  to  the  mucosa.  The  cervix  yw- 
sents  the  usual  appearance. 

The  uterine  cavity  is  7  cm.  in  length,  and  at  the  fundus  7  cm.  in  breadth. 
Its  mucosa  is  not  over  1  nun.  in  thickness.  It  is  smooth  and  glistening.  The 
appendages  are  apparently  normal. 

Histologic  Examination. — The  cervical  glands  in  places  reach  3  to  4  nun. 
in  diameter;  otherwise  the  mucosa  in  this  portion  is  unaltered.  The  cells  of 
the  new-growth  are  clinging  to  the  surface.  This  appearance  is  certainly  due  to 
the  fact  that  the  juice  of  the  tumor  has  oozed  out  when  pieces  Avere  being  excised 
for  examination.  Sections  from  the  body  of  the  uterus  show  marked  atrophy 
of  the  mucosa.  The  surface  epithelium  is  intact,  but  consists  of  low  cuboid  or 
almost  flat  cells.  The  glands  are  very  small,  but  are  normal  except  for  occasional 
dilatation.  The  stroma  of  the  mucosa  is  very  dense,  and  in  places  it  is  impossible 
to  differentiate  between  nmscle-bundles  and  altered  stroma. 

Situated  in  the  uterine  muscle  are  small  typical  myomata.  The  larger 
nodule,  occupying  the  anterior  wall  and  consisting  of  soft  tissue,  is  made  up  of  a 
framework  of  spindle-shaped  connective-tissue  cells  and  apparently  of  non- 
striped  muscle-fibers.  Its  stroma  contains  many  large  blood-vessels  and, 
roughly  speaking,  it  would  have  made  up  one-cjuarter  of  the  tissue.  The  major 
portion  of  the  tumor  consists  of  solid  masses  of  cells  which  vary  greatly  in  size. 
Some  are  rounded  or  polygonal  in  shape,  have  vesicular  nuclei,  and  bear  some 
resemblance  to  decidual  cells  (Fig.  144).  Others  contain  lai-ge  vesicular  nuclei, 
ten  or  twenty  times  the  size  of  those  in  the  near  vicinity.  Scattered  abundantly 
throughout  the  section  are  large,  deeply  staining  nuclei,  and  great  irregular 
masses  of  chromatin.  Everywhere  small  round  cells  are  to  be  .seen,  and  fre- 
quently polymor{)honuclear  leukocytes.  Scattered  throughout  many  portions 
of  the  tumor  are  large  and  small  vacuoles,  lying  between  cells  or  in  the  cell- 
protoplasm.  Frequently  masses  of  tumor-cells  are  found  ])rojccting  into  oi- 
lying  free  in  veins  or  aiicrics.  .Many  pails  of  the  tunioi'  ha\f  undci'gonc  com- 
plete necrosis  or  show  marked  fragmentation  of  uucKm. 

As  seen  from  the  description,  this  large  tumor  is  a  sarcoma  of  the  mixed-celled 
variety.  Whether  or  not  it  has  originated  from  the  myoma  it  is  impossible  to 
say  with  absolute  certainty.  The  appeai'ance  of  the  gross  specimen,  howe\-er, 
strongly  suggests  such  an  origin. 


220 


MVOMATA    OF    THK    UTKKrS. 


Gyn.  No.  7604.     Path.  No.  3865. 

S  a  r  {•  0  111  a  o  t'  the  j)  o  s  t  c  r  i  o  r  wall  of  t  h  v  u  t  c  v  us,  o  r  i  g  - 
i  n  a  t  i  n  ii  i  n  a  111  y  o  111  a  (  F  i  ^i .  1  1  ">  )  :  metastases  in  t  li  c  1  u  11  i^s 
and   ('  n  (1  0  {'  a  r  (I  i  u  ni  . 

K.  \l..  white,  aficd  fort y-t our.  niarricd.  Adinittcd  Fchruaiy  27.  liHK).  She 
has  l)een  married  nineteen  years,  hut  has  had  no  children  and  no  miscarriages. 
The  menses  have  usually  been  regular,  of  five  days'  duration,  and  accompanied 
by  con.siderable  pain  before  the  flow  commenced.  For  the  past  five  or  six 
months  there  has  been  a  slight  l)lood-stained,  watery  discharge.  The  bowels 
have  i)een  consti|)ate(l.  and  there  has  been  some  bui'iiing  and  increased  freciuencv 


BUdier 


Fk;.  145. — Sarcoma  of  thk  Postkhior  I'tkrink  Wall,  Oricinatixg  in  a  Mvo.ma. 
Path.  No.  :j86o.     The  uterus  i.s  much  enlargeil.  mainly  from  the  presence  of  a  growth  in  its  posterior  wall. 
Histologic  examination  shows  this  to  be  a  sarcoma  <ieveloping  in  a  myoma.     It  is  firmly  fixed  in  the  pelvis,  being 
intimately  blen(le<l  with  the  rectum.     The  bladder  is  drawn  high  into  the  abdomen. 


of  micturition.  At  one  time  the  ])atient  had  the  cervix  dilated  for  dysmenon-hea, 
and  a  polyj)  was  removed  from  the  uterus.  She  had  definite  signs  of  stone  in  the 
left  kidney,  and  thinks  .she  pa.^.^ed  a  stone  into  the  bladder,  after  which  the  renal 
svniiptoms  di.sai)peared.  For  the  past  three  or  four  months  there  has  been  pain 
in  the  j)eK-ic  region.  I'adiating  down  the  legs,  and  the  patient  has  noticed  the 
abdomen  increasing  in  size  for  two  months.  For  the  last  three  months  there  has 
been  considerable  difficulty  in  voiding,  and  at  times  the  flow  of  urine  would 
suddenly  stop.  There  has  always  been  great  straining  and  (jl)stinate  constipation. 
She  has  been  in  bed  for  eight  weeks,  and  has  been  taking  large  quantities  of 
morphin.  For  the  ])ast  w(>ek  .she  has  b(>en  unable  to  void  at  all,  catheterization 
being  necessary. 


MYOSARCOMA  OF  thp:  uti-:rus.  221 

Operation,  March  3,  1900.  The  vagina  was  encroached  upon  post(U-iorly  b}^  a 
cystic  tumor  filHng  the  cul-de-sac.  The  cervix  was  small  and  soft,  and  pushed 
above  the  symphysis.  The  urethra  was  jammed  against  the  symphysis,  and  the 
bladder  reached  to  the  uml)ilicus.  As  a  great  deal  of  difficulty  was  experienced  on 
account  of  the  dense  adhesions  (Fig.  145),  the  uterus  was  bisected.  As  soon  as  the 
uterus  was  split  there  was  a  gush  of  blood-stained  serous  fluid  from  the  cavity. 
The  lower  portion  of  the  uterus  was  occupied  by  a  soft,  stringy  substance,  re- 
sembling striated  muscle,  much  softer  and  darker  in  color  than  usual,  and  very 
vascular.  There  was  alarming  hemorrhage  wherever  it  was  cut.  An  opening 
was  made  into  the  l)ladder,  and  urine  escaped  into  the  peritoneal  cavity.  The 
patient  at  the  time  of  operation  was  exceedingly  weak,  and  there  was  a  good  deal 
of  shock.  She  grew  weaker,  had  much  abdominal  pain  and  nausea,  and  died 
on  March  14th,  eleven  days  after  the  operation. 

Path.  No.  3865.  The  specimen  consists  of  the  uterus,  together  with  both 
tubes  and  ovaries.  The  uterus  has  been  divided  into  two  portions  and  is  con- 
siderably enlarged,  being  twice  the  size  of  a  man's  fist.  Accurate  measurements 
cannot  be  given  on  account  of  the  mutilation  of  the  specimcni.  The  tubes  and 
ovaries  are  bound  together  by  dense  adhesions,  and  so  greatly  distorted  as  to  be 
scarcely  recognized.  Both  ovaries  have  been  converted  into  cysts,  and  are 
almost  completely  embedded  in  adhesions.  One  is  approximately  the  size  of  a 
small  orange.  The  cyst  on  the  left  is  apparently  the  size  of  a  hen's  egg:  it 
presents  numerous  partitions  and  trabecukr,  which  show  that  it  was  multilocular. 
The  posterior  portion  of  the  ovary  is  occupied  by  a  mass  of  tissue  com])osed  of 
stroma,  in  which  are  masses  of  tissue  irregular  in  shape.  The  posterior  wall  of 
the  uterus  and  the  anterior  half  of  the  uterus  present  numerous  dense  adhesions. 

Histologic  Examination. — The  surface  of  the  mucosa  has  to  a  great  extent 
been  mechanically  removed,  but  in  a  few  places  is  fairly  well  pr(>served,  antl 
here  the  surface  is  smooth.  The  uterine  glands  are  of  the  usual  numbei-  and  are 
normal.  Others  are  considerably  dilated.  The  stroma  is  dense.  The  muscular 
tissue  innnediately  beneath  the  mucosa  is  normal.  In  the  uterine  wall  the 
nuiscle-cells  end  abruptly;  in  some  places  they  ai'e  abundant  and  stain  intensely; 
they  vary  somewhat  in  size.  In  thecentei'of  the  tuinoi' the  arrangement  of  cells 
in  bunches  is  less  evident  and  the  cells  are  less  distinct,  until  finally  there  is  a 
mass  of  oval  or  elongate  cells  having  no  definite  arrangemcMit.  and  traversing  it 
are  numerous  bunches  of  blood-vessels.  Many  of  the  cells  aiv  inimUe.  Hunches 
of  fibers  still  persist  in  the  tumor  mass,  and  weiv  it  not  foi'  the  ])i-esence  of  ir- 
regular masses  of  cells,  the  diagnosis  would  be  myoma.  In  some  places  the  c{>l]s 
are  small;  in  othei-  ])lac(>s  the  nuclei  are  se\-eral  times  iheir  usual  size.  The 
picture  is  one  of  t  \'pical  sarcoma  de\-elo|)ing  in  t  he  intei'ioi-  of  a  myoma,  although 
the  cell  changes  are  not  so  marked  as  are  usua.ll>-  found. 

A  u  t  o  p  s  y  No.  1  5  0  3  ,  M  a  r  c  h  11,  1  <)  0  0  .  .\  n  a  t  o  m  i  c 
diagnosis:  Pv  e  c  e  n  t  s  u  i'  g  i  c  a  1  incision,  w  i  t  h  d  r  a  i  n  r  e  a  c  h  - 
i  n  g    into    t  h  e    p  e  1  \'i  c    c  a  \'  i  t  >'  :     i'  e  c  e  n  t    a  m  p  u  t  a  I  i  o  n    o  f     t  h  e 


222  MYOMATA    OF    TlIK    UTKRUS. 

II  t  (M-  u  s  :  I)  1  ()  ()  (1  -  (•  1  ()  t  fi  1  1  i  11  g  J)  e  1  V  i  s  ;  g  e  n  e  r  a  1  a  n  e  ni  i  a  of 
all  ()  r  g  a  n  s  .  1^  o  t  h  h  r  a  ii  c  h  o  s  of  o  v  a  r  i  a  n  v  c  ins  t  h  r  o  in  - 
b  o  s  e  (1  ;  ^  a  n  ti  r  c  n  e  o  f  left  o  v  a  r  y  ;  involve  m  e  n  t  o  f  1  u  m  - 
bar  <!;  1  a  11  1 1  s  by  s  a  r  e  o  m  a  t  o  u  s  metastases.  M  e  t  a  s  t  a  s  e  s 
in  the  1  u  n  2:  s  .  \'  c  g  e  t  a  t  i  o  n  s  on  the  e  h  o  r  d  [c  t  e  n  d  i  n  e  ffi 
of  the  t  r  i  c  u  s  p  i  d  v  a  1  v  i'  a  11  d  o  n  t  h  v  c  o  1  u  ui  11  a'  e  a  r  n  e  ve, 
o  f  t  h  ('  r  i  ^'  h  t  \-  ('  II  t  ]■  i  {■  1  (■  :  b  r  o  n  e  h  o  ]>  11  c  11  in  o  n  i  a  ;  el  o  u  d  y 
swelling  of  t  h  V  V  i  s  c  c  r  a  :  f  o  e  a  1  a  r  e  a  s  o  f  11  e  c  r  o  s  i  s  i  n 
the  liver:  cholelithiasis:  <:;  a  1 1  -  s  t  o  11  e  in  the  diver- 
t  i  ('  u  1  u  111     0  f    \'  a  t  e  r  . 

On  ()])enini!;  the  abdominal  cavity  the  jieritoneiim  is  found  to  be  smooth  and 
glistening;.  The  intestinal  loops  are  somewhat  distended  with  gas.  At  the  site 
of  the  wound  there  are  firm  adhe.-tions  between  intestinal  loops  and  the  per- 
itoneum. I'^xcept  for  these  adhesions  the  intestinal  coils  are  quite  free.  Filling 
the  entire  pelvis  is  a  large  blood-clot  which  appears  to  be  several  days  old. 

The  left  ovary  is  dark,  firm,  tense,  and  on  section  is  found  to  be  filled  with  a 
blood-clot  and  necrotic  material.  There  is  no  rupture,  and  nothing  can  be 
found  in  the  ))elvis  to  account  for  the  (juantity  of  blood  present. 

Intestines:  The  rectum  and  greater  part  of  the  colon  aj)pear  practically 
normal.  The  cecum,  however,  is  considerably  distended.  On  examination, 
the  mucosa  is  found  to  be  injected  but  intact. 

Lungs:  The  metastases  in  the  lungs  are  rather  extensive. 

The  hemorrhage  in  this  case  was  apparently  not  the  result  of  bleeding  from 
vessels  of  any  size,  but  of  a  general  oozing.  There  is  little  wonder  that  the  patient 
in  her  weakened  condition  did  not  sur\i\'e  the  operation. 

Gyn.  No.  6724.     Path.  No.  2946. 

r  t  e  r  i  11  e  m  y  o  111  a  u  11  d  e  i'  g  o  i  11  g  c  y  s  t  i  c  s  a  r  c  o  m  a  t  o  u  s 
d  e  g  e  n  e  rati  o  n  . 

Al.  F.,  white,  aged  t weiity-.'^even,  single.  Admitted  February  26:  dis- 
charged A])ril  1,  1S99.  The  family  hi.^tory  is  not  important.  The  patient  as 
a  girl  was  always  healthy.  The  menses  commenced  at  fifteen,  were  regular, 
painful,  but  not  especially  copious.  The  patient,  about  four  weeks,  ago,  noticed 
pain  and  swelling  of  her  ankles,  associated  with  some  discomfort  in  the  back  and 
lower  ])art  of  the  abdomen.  During  the  last  four  years  her  periods  have  been 
regular  except  for  the  last  seven  months.  Hince  August,  seven  months  ago, 
the  periods  have  occurred  every  two  weeks  and  have  been  profuse  and  painful. 
The  last  menses  ceased  about  ten  days  ago.  On  abdominal  examination  a  smooth, 
firm,  spheric,  immobile  tumor  mass  can  be  felt  rising  from  above  the  symphysis 
and  extending  to  the  umbilicus;  a  little  to  the  left  of  the  median  line  a  second, 
but  smaller,  mass,  apparently  continuous  with  the  first,  crosses  the  median  line 
to  the  right. 

O])eratioii,   February  27,   1899.     Abdominal   myomectomv.      For  nearlv  two 


MYOSARCOMA    OF    THK    ITRRUS.  223 

days  after  operation  the  patient  had  a  great  deal  of  abdominal  ))ain  and  a  feel)le 
and  rapid  pulse;  there  was  also  a  considerable  degree  of  abdominal  distention. 
Nervous  symptoms  were  prominent  during  convalescence,  but  gradually  abated, 
and  she  was  discharged  on  April  1,  1899.  Her  highest  postoperative  temperature 
was  102.5°  F.,  on  the  day  following  the  operation.  The  pulse  on  that  day  was 
very  feeble,  rising  to  140.     From  this  time  on  there  was  a  gradual  drop  to  82. 

Path.  No.  2946.  The  specimen  consists  of  several  myomata,  the  largest  11 
cm.  in  diameter,  a  smaller  one,  5  cm.  in  diameter,  and  a  third  still  smaller  one, 
to  which  is  attached  a  piece  of  the  uterine  wall.  These  myomata  are  apparently 
edematous.  Situated  just  below  and  to  the  right  of  the  tube  is  a  small  nodule. 
9x6x4  mm.  Its  surface  is  slightly  lobulated,  and  a))])arently  consists  of  fibrous 
tissue.  The  large  myoma  presents  a  different  picture  from  those  usually  seen. 
It  is  made  up  chiefly  of  coarse  fibers  forming  bundles,  which  sometimes  present 
a  whorl-like  arrangement,  while  in  other  places  they  interlace  in  various  direc- 
tions. The  nuclei  vary  greatly  in  size  and  shape.  They  are,  for  the  most  part, 
oval  or  fusiform,  but  may  be  spheric.  Many  are  several  times  the  usual  size, 
and  frequently  large,  deeply  staining  masses  of  chromatin  are  seen,  or  several 
cells  seem  to  have  bunchetl  together  and  to  have  coalesced,  while  the  nuclei  have 
remained  distinct.  Some  of  the  nuclei  stain  palely  and  show  a  few  rather 
coarse  granules  of  chromatin,  while  others  take  an  intense  homogeneous  stain. 
No  definite  division  of  the  cells  is  to  be  seen.  In  some  areas  the  fibrillated 
tissue  has  been  replaced  by  a  homogeneous  or  granular,  (^osin-stained  substance 
containing  a  few  degenerated  cells.  In  some  parts  of  the  tumor  the  cells  are  verv 
abundant  and  closely  packed  together,  while  at  other  ]K)ints  they  are  f(nv  in 
number.  Near  the  periphery  of  the  myoma  typical  myomatous  tissue  is  present. 
There  is  moderate  vascularity  of  the  tumor.  The  growth  is  undoubtedly  an 
early  sarcoma,  occurring  in  the  interior  of  a  myoma. 

The  patient  was  in  good  health  when  heai'd  from  on  January  1,  1907, 
about  eight  years  later. 

Gyn.  No.  6045.     Path.  Nos.  231 1  and  2314.     Autopsy  No.  1085. 

Multiple  an  d  s  u  b  j)  e  r  i  t  o  n  e  a  1  u  t  e  r  i  n  e  m  y  o  m  a  t  a  ,  w  i  t  h 
S  a  r  c  o  m  a  t  o  u  s  d  e  v  e  1  o  p  m  e  n  1  in  t  h  e  i  n  t  c  r  i  o  r  o  f  a  m  y  o  111  a 
(Figs.  146-155). 

E.  F.  M.,  white,  aged  fifty-six.  single.  A.imittcd  April  21;  dicl  Aj.ril  23. 
1898.  The  patient  complains  of  tightness  in  I  he  abdoincii.  acc(iiii])ani('il  by 
abdominal  swelling.  Her  menses  began  at  foiii'lccn  and  were  regular,  lasting 
from  one  to  one  and  one-half  days.  The  How  was  scanly.  The  inrns(>s  (-(^ascd 
six  years  ago.  Micturition  has  been  more  iVciiui'iil  tli.aii  iionnal  tni-tlic  ))ast  two 
or  three  months.  The  bowels  arc  conslipatcd.  The  abdomen  is  much  disleinled, 
and  on  j)al])ation  several  nodulai'  and  tendci"  masses  can  be  felt.  There  is  shght 
edema  of  the  labia. 

Operation,  A])ril  23.  l']\ploratory  hii)arotoiny  was  pcrfoi'nied.  but  nothing 
was  removed.     The  patient  died  on  Apiil  23,  bSilS. 


224 


MVOMATA    OF    THK    ITKIU'S. 


A  u  t  o  {)  s  y  No.  1  0  s  5  .  A  ii  ti  t  o  in  i  c  d  i  a  ^  n  o  sis  :  U  t  o  r  i  ii  o 
m  y  o  111  a  t  a  ii  ii  d  c  r  g  o  i  n  o;  s  a  r  o  o  in  a  tons  d  v  g  v  n  c  rati  o  n  ; 
gene  r  a  1     a  n  cm  i  a     o  f    t  h  v    o  r  «:  a  ii  s  . 


Fig.  146. — Sarco.matous  Transformation  of  a  Multinodular  Pkounculatkd,  Sl-bim;kitonkal  Myoma. 
Gyn.  No.  604.5.  Path.  Nos.  2.311  and  2314.  The  specimen  was  obtained  at  autopsy,  .\ttached  to  the  fumiu.s 
by  a  rather  broad  pedicle  is  a  multinodular,  lobulated  myomatou.s  tumor.  Dr.  Louis  Livingood,  who  made  the 
autopsy,  noted  that  the  tumor  as  a  whole  was  softer  than  a  myoma  and  that  it  tore  readily.  The  central  portion 
of  the  lobulations  showed  degeneration,  but  in  the  outer  portions  typical  myomatous  tissue  was  still  visible.  For 
the  histologic  pictures  showing  that  the  sarcoma  iiriginatpd  frmn  a  nuiligiKint  metamorijhosis  of  the  muscle-fibers 
see  Figs.  147-155. 

Tiic  cdiics  of  the  al)d(»iiiinal  wound  arc  well  approximated.  'Hie  intestinal  coils 
occupy  the  uppci'  poi'tion  of  the  ca\'it\',  the  lower  part  being  filled  with  a  large 
tumor  s|)riiiging  from   the  uterus.     The   lowei'   intestinal   coils  and  the   tumor 


MYOSARCOMA    OF    THE    UTERUS. 


225 


mass  are  coveivcl  with  blood,  which  is  tni versed  hy  shreds  of  tissue  suggestino; 
siiiah  blood-vessels.  The  appearance  resembles  that  seen  in  an  organizing 
blood-clot.  The  intestinal  coils  are  loosely  attached  to  the  U])iX'r  part  of  the 
tmnor,  and  at  first  completely  hid  it  from  view. 

Dr.  Livingood  kindly  placed  the  ]x4vic  organs  at  the  disposal  of  the  gyneco- 
logical department. 

Path.  No.  2311  and  2314.  The  specimen  consists  of  the  uterus,  with  a  large 
tumor  springing  from  the  fundus,  and  also  of  the  intact  tubes  and  ovaries.  The 
uterus  is  distorted  by  the  presence 
of  a  tumor.  The  uterus  is  8  cm. 
long,  5.5  cm.  broad,  and  2  cm.  in 
its  anteroposterior  diameter.     The 


V   '*<^ 


-X 


Fig.  147. — Suspicious  Cell  Changes  in  a 
Myoma.  (X  460  diam.) 
Path.  No.  2314.  a  represents  approximately 
the  usual  size  of  the  nucleus  in  a  muscle-fiber. 
-•Vt  b  one  cell  is  overlapping  another.  Both  are 
much  enlarged.  At  c  we  have  a  giant-cell  con- 
taining six  nuclei,  all  of  which  are  larger  than 
those  of  normal  muscle-fibers.  There  is  some 
Ijolymorphonuclear  and  small-round-celled  in- 
filtration, as  indicated  by  d.  The  presence  of 
the  large  nuclei  at  b  and  c  is  somewhat  sug- 
gestive of  sarcoma,  but  these  are  occasionally- 
found   in  benign  myomata. 


Fig.  148. — Early  Sarcomatous  Changes  in  a  Myoma 
CX  225  diam.) 
Path.  No.  2314.  Much  of  the  tissue  has  undergone 
hyaline  degeneration,  as  indicated  by  a.  At  b  we  have 
muscle-fibers  of  the  usual  size;  at  b'  is  a  nucleus  twice  a.s 
large  as  normal,  and  at  b"  the  nuclei  are  not  only  much 
larger,  but  also  contain  an  increased  amount  of  chromatin, 
c,  c',  c"  also  depict  the  gradual  transformation  of  muscle 
nuclei  into  very  large  ones,  so  suggestive  of  a  malignant 
change.  The  nucleus  d  is  enlarged,  stain.s  deeply,  and 
has  an  irregular  outline.  The  cell  e  is  particularly  well  out- 
lined, lying  free  in  the  hyaline  tissue.  It  is  greatly  en- 
larged, and  the  nucleus  is  fully  five  times  the  normal  size, 
contains  much  chromatin,  and  two  hyaline  droplets.  From 
this  field  alone  we  would  strongly  suspect  sarcoma,  but  could 
not  venture  a  positive  diagnosis. 

cervical  canal  is  6  cm.  in  length  and  its  mucosa  is  slightly  granular.  The 
uterine  cavity  is  4.3  cm.  long  and  1.5  cm.  broad  at  the  fuiulus.  The  mucosa 
lining  the  uterine  cavity  averag(>s  2  mm.  in  thickness  and  has  a  .smooth  surface, 
but  a  few  of  the  glands  are  dilated,  .some  reaching  1  mm.  in  diametei-. 

S])ringing  from  the  fundus  by  ;i  pedicle.  3.5  em.  in  diameter,  is  a  large  lobu- 
lated  tumor,  about  I  he  size  of  ;iii  adiiH 's  he;id,  ineasuiiiig  iM  \  Hi  \  11  cm.  (l''ig. 
14()).  This  is  the  large  mass  that  fihed  the  lowef  ;ibd(iMien.  It  is  irregularly 
rtnighened,  ])inkish  in  color,  and  on  section  a))]ieai's  librillated.  Some  ol  the 
fibers  present  a  i)arallel  aiiangeineiil  :  others  are  grouped  concentrically.  At 
many  points  the  tissue  ap])ears  to  ha\('  undei'gone  degeneration.  Taken  as  a 
1.") 


22() 


MYOMATA    OF    THK    I'TFJU'S. 


whole,  tile  tumor  is  softer  than  an  oi'(hiiar\'  inyoiua.  and  tears  more  readily. 
The  portion  of  the  tumor  which  shows  the  least  degeneration,  however,  presents 
the  typical  myomatous  appearance.  Situated  in  the  j)osterior  wall  of  the  uterus 
is  a  small  myoma,  2  cm.  in  diameter. 

Ivijiht  side:  The  tul)e  on  passiniz;  out  ward  10  cm.  is  lost  on  tlie  .surface  of  the 
tumor.  It  averages  5  cm.  in  thickness.  The  ovary  measures  o  x  2  x  0  cm. 
Its  outer  j)ole  is  adherent  to  the  tumor. 


l'"i<;.  149. — Sar<  o.MATOLS  Transformation-  of  Myomatov.s  Tissue.  (X  215  diam.) 
Path.  No.  2314.  At  a  the  nuclei  of  the  muscle-fibere  are  pale-.staining  and  comparatively  normal  in  .size. 
In  the  area  indicated  by  b.  and  including  about  one-.sixth  of  the  field,  the  muscle-bundles  have  been  cut  trans- 
versely. The  majority  of  the  fibers  are  normal,  but  here  and  there  (ci  the  nuclei  are  enlarged,  slightly  irregular, 
and  stain  deeply.  In  the  area  d.  where  the  fibers  have  been  cut  longitudinally,  the  grarlual  transition  of  normal 
nuclei  into  the  large,  irregular,  and  deeply  staining  ones  can  be  followeil.  In  the  area  e  the  same  gradual  transi- 
tion of  average-.sized  nuclei  into  large  and  deeply  staining  ones  can  be  outlinetl. 

Left  side:   The  ajjjx'ndages  are  normal. 

The  glands  along  the  aorta  are  slightly  enlarged:  no  nieta.stases  are  to  be 
detected  in  them  or  in  any  of  the  organs.  The  right  lung  shows  a  good  deal 
of  con.solidation  in  the  lower  lobe,  and  cultures  re\'eal  a  lanceolate  di})lococcus, 
probatily  M.  laneeolatus. 

Heart  :  The  coronary  arteries  are  diffusely  thickened.  The  heart  valves  are 
normal. 

Histologic  Examination. — Sections  from  the  denser  poititjiis  oi  the  tumor 


MYOSARCOMA    OF    THH    ITKRUS. 


227 


show  non-striped  muscle-fibors  closely  packed  tof^ether.  Sometimes  these  are 
cut  ti-ansversely,  but  in  many  places  lono;itudinally ;  or  they  run  in  and  out  in 
ev(>rv  dirc^ction.  The  ])icture  is  that  of  an  oi'dinary  iiix'oma.  Here  and  there 
are  foci  of  hyaline  degen(>ration,  sharply  tlehned  from  the  surrountling  muscle 
and  frequently  entirely  devoid  of  muscle-fibers.  Occasionally  the  degeneraticMi 
is  more  diffuse,  isolated  Inmdles  of 
nuiscle  undergoing  hyaline  trans- 
formation. In  other  portions  of  the 
tumor  the  picture  is  difl'erent. 
Here  dark-staining  areas  can  be 
detected  with  the  low  ])ower.  On 
careful  examination  they  ai'e  found 
to  consist  of  enlarged  nuclei  (Figs. 
147,  148,  149,  150,  151,  152,  153, 
154,  and  155).  Some  of  these  are 
spindle-shaped  and  four  or  five  times 
the  size  of  those  surrounding  them ; 
they  stain  very  deeply,  and  their 
chromatin  is  finely  granular.  All 
gradations  from  the  ordinary  muscle 
nuclei  to  these  enlarged  and  deeply 
staining  ones  are  demonstrable.  In 
the  neighborhood  of  these  there  are 
also  very  large  and  irregular,  deeply 
staining  masses  of  chromatin,  at 
least  twenty  times  the  size  of  an 
ordinary  nucleus.  Many  of  these 
enlarged  cells  are  found  scattered 
throughout  tlie  tissue.  ( )n  examina- 
tion of  still  other  portions  of  the 
tumor  a  very  unusual  |)icture  is 
noted.  The  miclei  of  the  cells 
become  about  twice  the  size  of 
those  of  an  oi'diuai'v  muscle-fiber. 
There  is,  h()we\'ei\  no  alteration  in 
the  ai"i-angement  of  the  (ibei's.  'i'liis 
ai'ea    is    undoubtedl}'    malignant    in 

character,  and  there  is  a  direct  I  ranslonnat  ion  fi'oni  the  myomatous  into  sai'- 
coinatous  tissue,  characteri/etl  pi'iinai'ily  by  ;ni  increase  in  size  of  the  nuclei 
and  the  tendency  to  become  iri-egulai'  in  (Uitline,  and  by  a  considei'able  augmen- 
tation in  the  chromatin.  l'"rom  some  poitions  of  the  t  unioi- all  t  I'aces  of  myoma 
ha\'e  di.sa])))eared,  and  the  cells  liaxc  o\al,  \"esiculai'  miclei.  .\  numbei'  of  them 
contain   miclear  figures.     The  nuclei  are  very  closely  packed  together,  and  the 


Fig.  150. — Gradual  but  Direct  Transitiox  of  Myo- 
matous into  Sarcomatous  Tissue.  (X  210  (liam.) 
Path.  No.  'I'.WA.  a  i.s  tlie  normal  .size  of  the  nucleu.s  of 
the  iinisclc-fiher.  .\t  h  we  see  the  gradual  transition  into 
nuclei  fvill.v  five  or  six  times  a.s  large.  At  c  the  nuclei  are 
al.so  normal,  hut  at  d  considerably  enlarged  and  more  ileeply 
staining.  .\t  e  they  are  grouped  and  still  more  enlarged, 
and  at  f  are  of  such  a  size  as  to  very  strongly  s\iggest  a  sar- 
comatous change.  \\\  the  vicinity  of  g  the  same  gradual 
transition  from  normal  musde-fihers  into  enlargeil  anil 
suspicious  ones  is  seen.  The  groups  of  very  large,  irregu- 
lar, and  deeply  staining  nuclei  at  h  and  i  leave  absolutely 
no  doul)t  as  to  the  malignant  character  of  the  proce.ss. 
.•-ionic  of  these  nuclc'i  i-oiitaiii  hyaline  droplets.  The 
tissue  shows  yjitjhl  >ni:ill-iouiiil  celled  intiltralion,  iis 
iiidieaii'il  li.\  U.  I'liis  |iiel\ire  liemonsl rates  clearl.v  the 
iriaihiMl    I  raii-iticiii   of  mu>c-le'lil>er>   into  sarcomatous  cells. 


228 


.MYOMATA    OF    THK    ITERUS. 


entire  })ieture  is  that  of  .sarcuiiia.      This  sareuiuatuus  tissue  does  not  show  a 
tendency   to    hyahne   degeneration,   but   where   the   tissue  dies,  it  undergoes 


V 


V 


I'.g.  1-. 

Sarcomatous  Trax!- 


Fig.  1.-,: 


■(formatiox  OF  Myom\tous Tissue.  (X  SSOdiani.)  Figs,  lol ,  152,  1.51J,  ami  1.54  are  from  the 
same  .specimen  (Path.  No.  2314);   all  are  enlarged  the  same  number  of  time.s. 

Via.  151. — a  represents  a  cross-section  of  a  myomatous  bundle  of  mu.scle-fib3rs.  At  b  are  cross-sections  of 
the  tips  of  muscle-fibers  too  near  their  ends  to  include  portions  of  the  nuclei,  c  is  a  cell  containing  two  nuclei, 
an<l  at  d  we  have  a  cell  containing  three  large,  deeply  staining  nuclei.  In  this  mu.scle-bundle  all  transitions  from 
normal  fibers  to  those  containing  very  large  and  suspicious  nuclei  can  be  traced,  e  is  the  nucleus  of  a  comparatively 
normal  muscle-fiber.  At  e'  the  nucleus  is  fully  twice  the  usual  size,  e"  is  much  enlarged,  contains  a  good  deal  of 
chromatin  and  several  hyaline  droplets,  e'"  shows  a  still  further  nuclear  enlargement,  together  with  a  tendency 
toward  the  formation  of  giant-cells.     At  f  there  is  a  distinct  giant-cell  formation. 

In  this  specimen  we  can  trace  the  gradual  transition  of  muscle-fibers  into  sarcoma  cells,  not  only  where  the 
fibers  have  been  cut  longitudinally,  but  also  where  they  have  been  cut  transversely. 

Fig.  152. — a  .shows  the  average  size  of  a  myomatous  muscle-fiber;  b,  c,  and  d  represent  the  various  stages 
in  the  enlargement  of  the  mu.scle-fibers.  e  is  a  very  much  enlarged  cell  containing  an  abundance  of  chromatin 
and  many  hyaline  droplets. 

Fig.  153. — a  repre.sents  the  average  size  of  the  nucleus  of  the  myomatous  muscle-cell,  b  shows  considerable 
enlargement,  but  the  nucleus  still  stains  palely,  c  is  much  enlarged,  contains  an  abundance  of  chromatin,  and 
one  hyaline  droplet,  d  is  a  greatly  enlarged  and  somewhat  irregular  nucleus,  containiiiK  iiuich  chroniatin  and 
many  hyaline  droplets. 

Fig.  154. — No  muscle-fibers  of  normal  size  are  to  be  seen.  At  a  the  nuclei  are  fully  twice  the  average  size, 
and  quite  a  number  of  cell-shadows  are  .seen  where  the  nucleus  is  wanting,  b  indicates  the  group  of  five  very 
large  nuclei,  containing  quantities  of  chromatin  and  many  large  and  small  hyaline  droplets,  as  indicated  by  c. 
(Figs.  152  and  1,53  are  in  themselves  very  suggestive  of  .sarcoma.  Figs.  151  and  154  indicate  beyond  doubt  the 
sarcomatous  character  of  the  growth.) 


coaguh\ti()n  necrosis.     Traversing  the  sarcomatous  areas  are  numerous  delicate 
l)l()o(l-\-e.ssels. 


MYOSARCOMA    OF    THP:    UTERUS. 


229 


This  is  a  most  instructive  case.  On  the  one  hand,  we  have  typical  myoma- 
tous tissue;  on  the  other  hand,  a  most  pronounced  example  of  sarcoma,  both 
situated  in  the  subperitoneal  myoma,  and  almost  isolated  from  the  uterus. 
Fortunately,  we  are  able  to  trace  the  direct  transition  of  the  myomatous  muscle 
into  the  sarcomatous  tissue.     For  those  who  are  ske])tical  as  to  the  sarcomatous 


Fig.  155. — Junction  of  Myom.a.tous  and  Sarcom.\tous  Tissuk.  (X  150  diaiu.  > 
Path.  No.  2314.  A  line  between  a  and  a  divides  the  field  into  an  upper  one,  compo.sed  of  myomatous  tis.sue, 
and  a  lower,  made  up  of  sarcoma-cells.  At  b  the  bundles  of  mu.scle-fibers  have  been  cut  transversely,  and  tho 
nuclei  accordingly  appear  round.  They  are  uniform  in  size.  In  the  vicinity  of  c  the  fibers  have  been  cut  leiiRth- 
wise.  The  sarcomatous  tissue  commencing  at  a  and  extending  to  the  lower  border  of  the  field  shows  no  definite 
arrangement,  but  consists  of  a  homogeneous  .sea  of  cells.  The  nuclei  of  these  cells  are.  for  the  most  part,  oval  and 
vesicular;  they  are  much  larger  than  those  of  the  muscle-fibers.  The  line  of  jum-lioii  between  the  niyotnatous  and 
sarcomatous  tissue  is  not  well  defined. 

transformation  ol'  iiiusclc-fiber.^  \\c  think  thai   the  hist()h»i^ic  picture,  as  .seen  in 
the  accompaiiyiiiii;  di'awiiigs,  will  t<iul  to  i-('iiio\-e  all  doulit. 


Gyn.  No.  8836.     Path.  No.  5032. 

S  a  r  c  o  111  a  o  f  t  h  c  u  t  c  i'  u  s  ;i  )»  ])  a  i-  cull  y  o  r  i  .ii  i  11  a  t  i  n  i:  i  11  a 
111  y  o  111  a  .      (J  1  i  II  i  c  a  1    d  i  a  [^  n  o  sis,    d  c  11;  c  n  c  r  a  t  c  il    111  >'  o  ni  a  . 

J.  \\.,  white,  a^cd  roiiy-citiht ,  niai'ricd.  .\diiiittcd  .luiic  IM:  died  ,Iune  IT), 
1905.     The  patient   cntcrctl  coinplainiii':;  of  uterine  heniorrhai2;e.     Her  menses 


230  M^OMATA    OF    THK    UTERUS. 

began  at  sixteen,  and  wvvv  rcmilar,  usually  lasting  throe  days.  She  has  been 
niarriod  twenty-five  years,  has  had  two  children  (twins),  but  no  miscarriages. 
Following  the  labor  she  had  a  severe  attack  of  puerperal  sep.sis,  the  fever  lasting 
for  three  weeks.  Her  last  inensti-ual  period  was  three  weeks  ago,  and  since  then 
she  has  had  a  slight  but  constant  bleeding,  although  not  severe  enough  to  cause 
any  marked  syinj)toms.  She  is  well  nourished.  The  abdomen  is  rounded  and 
synnnetric.  On  vaginal  examination  a  free  hemorrhagic  discharge  is  noted. 
The  cervix  is  high  up.  pointing  posteriorly.  In  front  of  the  cervix,  and  between 
it  and  the  symphysis,  is  a  large,  i-ounded  mass,  reaching  half-way  to  the  um- 
bilicus. This  a)i]iears  to  be  fluctuating,  and  is  apparently  continuous  with  a 
hard  mass  poslerioi'ly,  and  resting  more  or  le.ss  on  the  .sacral  promontory. 

Operation.  Panhysterectomy.  It  was  found  necessary  to  do  a  bisection  on 
account  of  adhesions.  Both  the  bladder  and  rectum  were  injured  and  were  im- 
mediately re])aire(l.  Two  j)el\-ic  drains  were  introduced,  and  also  a  retention 
catheter.  The  j)ulse  was  thready  and  weak  throughout  the  entire  operation, 
being  hardly  perceptible  when  the  o])eration  was  started.  The  l)ladder  anteriorly 
had  been  cai'i'ied  well  up  above  the  symphysis  by  adhesions,  and  posteriorly 
there  were  many  adluvsions  to  the  bowel,  some  of  which  were  very  dense.  The 
))atient  on  her  I'eturn  to  the  ward  was  nnich  collapsed,  notwithstanding  the 
ra])idity  with  which  the  operation  was  performed.  Her  pulse  was  b30,  very 
weak  and  irregular,  and  the  extremities  were  cold.  In  spite  of  stimulation  she 
gradually  grew  worse,  and  died  the  same  afternoon. 

Path.  No.  5032.  The  specimen  consists  of  a  bisected  uterus  with  the  lateral 
appendages.  The  whole  mass  measures  14  x  10  x  10  cm.  The  outer  surface  is 
everywhere  rough  and  covered  with  adhesions.  The  uterus  is  more  or  less 
symniet rically  enlarged,  on  accoimt  of  the  soft,  fluctuant  tumor  which  has 
develo])ed  in  the  posterior  wall.  The  anterior  wall  is  o  cm.  in  thickness  and  of 
normal  appearance.  The  uterine  cavity  is  10  cm.  in  length.  The  nuicosa 
appears  normal.  On  cross-section  the  myoma  presents  a  somewhat  edematous 
a])pearance.  The  lateral  structures  are  adherent,  but  not  much  eidarged.  The 
specimen  is  mutilated,  making  a  more  accurate  de.scri])ti()n  imj)o.ssible.  Macro- 
scopically,  the  diagnosis  is  interstitial  myoma  with  adhei'ent  apj)endages.  Scat- 
tered throughout  the  walls  of  the  uterus  are  several  small  myoniata,  but  the 
main  growth  is  exceedingly  soft,  and  gradually  l)lends  with  the  surrounding 
muscle,  being  in  no  way  so  sharply  circumscribed  as  an  ordinary  myoma. 

Histologic  Examination. — Tlie  growth  apparently  arises  from  the  nm.scle. 
-Vll  t  ransition  stages  from  muscle-fibers  to  those  of  a  malignant  type  can  be  traced. 
The  nuclei  gradually  become  larger;  they  stain  more  deej)ly,  and  finally  all  evi- 
dence of  nniscle  structure  di-sappears.  In  .some  j)laces  the  ai'rangement  is  that 
of  a  myoma:  in  other  places  there  is  no  definite  ari'angenient .  \o  cell  division 
is  evident.  The  blood-N'essels  are  well  foi'nied.  The  diagnosis  of  sarcoma  is 
certain. 

This  case  demonstrates  the  danger  in   the  routine  atloption  of  bisection  of 


MYOSARCOMA    OF    THE    UTKRUS.  231 

the  uterus.  It  is  impossible  to  tell  whether  the  sarcoma  is  really  due  to  a  break- 
ing-down of  a  myoma,  but  the  evidence  is  strongly  in  favor  of  it.  At  any  rate, 
we  have  a  sarcoma  associated  \\ith  a  myoma. 

Gyn.  No.  8610.     Path.  No.  4823. 

Sarcoma  of  the  uterus  apparently  originating 
from  a  myoma. 

M.  G.,  white,  aged  thirty-nine,  married.  Admitted  March  27:  discharged 
April  23,  1901.  Clinical  diagnosis:  Uterine  myoma  with  sarcomatous  degenera- 
tion. The  patient  entered  complaining  of  painful  menstruation  and  constant 
backache.  Her  menses  began  at  fourteen  and  were  usually  regular,  lasting  three 
or  four  days.  In  August,  1900,  the  patient  had  a  slight  bleeding  after  her 
regular  period  was  over.  In  February,  1901,  she  had  two  periods,  and  for  the 
last  month  the  bleeding  has  been  constant.  The  patient  has  been  married 
seventeen  years  and  had  one  child,  sixteen  years  ago.  She  has  had  much 
pain  in  the  lower  abdomen  for  ten  months,  and  backache  for  years.  The  abdo- 
men is  full,  rounded,  everywhere  soft  except  in  the  hypogastric  region,  where 
there  is  considerable  resistance  on  deep  palpation.  On  vaginal  examination  the 
cervix  is  found  low^  dowm,  lying  to  the  left  side.  Springing  from  the  cervix  and 
filling  the  superior  strait  is  a  smooth,  hard,  rounded  mass,  apparently  extending 
two-thirds  of  the  w'ay  to  the  umbilicus.     This  mass  is  somewhat  fixed. 

Operation.  On  opening  the  abdomen  a  purplish  tumor  mass  was  found 
choking  the  pelvis.  This  resembled  a  cystic  ovarian  tumor,  and  was  so  firmly 
wedged  in  the  pelvis  that  it  could  not  be  pushed  up.  It  was  verj^  adherent  on  the 
left  to  the  pelvic  brim,  and  also  somewhat  friable,  suggesting  malignancy.  Bi- 
section was  followed  by  very  little  hemorrhage.  The  cervix  was  split  for  drainage, 
as  there  was  considerable  persistent  oozing.  For  the  first  day  after  operation  the 
patient  had  considerable  oozing  from  the  vagina.  She  gained  rapidly  and  was 
discharged  in  good  condition. 

Path.  No.  4823.  The  specimen  consists  of  a  large  uterus  with  the  tubes  and 
ovaries  attached.  The  portion  of  the  uterus  present  measures  12  x  14  cm. 
Occupying  the  anterior  portion  of  the  cavity  is  a  nodular  growth.  The  nodules 
vary  from  0.5  to  3.5  cm.  in  diameter.  At  first  sight  they  apj)ear  to  l)e  cystic, 
but  on  careful  examination  the  majority  are  found  to  be  solid.  'Vhr  smaller  arc 
smooth,  and  on  palpation  are  found  to  be  soft.  The  larger  ones  |)resent  a  mottled 
appearance,  being  pink,  dark  red,  or  red  in  color,  as  a  result  of  the  appearance  of 
the  blood-vessels,  which  at  certain  points  vary  considerably  in  number.  The 
larger  nodules  arc  very  soft ,  and  hci-c  and  there  apjx'ai' to  be  cystic.  On  section, 
the  growth  occupying  the  antei'ior  wall  seems  to  consist  of  one  dilTuse  mass.  In 
the  central  portion  it  resembles  m\'omat()Us  tissue,  and  numerous  strands  of 
tissue  can  be  seen  running  in  all  directions.  In  o\'er  one-hall  oi  the  specimen. 
particularly  in  the  outlying  i)ortions,  a  very  homogeneous  appearance  is  present. 
These  areas  are  very  translucent,  and  stand  out  in  sharp  contrast  to  what  ap- 


232  MVoMATA    OF    THE    VTERUS. 

pears  to  Ix'  inyoniatoiis  tissue.  It  is  tiiis  homogeneous  and  translucent  growth 
tiiat  forms  the  bosses  or  ncxhdes  on  the  surface. 

liight  side:  The  tube  is  7  em.  long  and  has  a  patent  fimbriated  extremity. 
The  ovary  is  apparently  intact.  The  utero-ovarian  ligament  contains  a  sub- 
peritoneal nodule,  1.5  cm.  in  diameter.  This,  on  section,  is  perfectly  white  in 
color  and  homogeneous  in  structure.  The  ovary  measures  3x2x2  cm.;  it  is 
covered  with  delicate  adhesions,  and  contains  a  dilated  corpus  luteum.  Between 
the  tube  and  ovary  is  a  lobulated  mass,  2  cm.  in  length,  1.5  cm.  in  breadth,  and 
approximately  1  cm.  in  thickness.  On  section,  it  is  found  to  be  made  up  of 
distinct  foci  of  a  homogeneous  growth.  They  ar(>  without  doul^t  extensions 
from  the  uterine  growth. 

Left  side:  The  tube  is  7  cm.  in  length,  and  is  small  throughout  its  course. 
At  its  proximal  end,  for  a  distance  of  2  cm.,  it  is  represented  by  a  flattened  band, 
1  cm.  in  thickness.  The  fimbriated  extremity  is  free,  but  at  several  points  are 
milky-white  areas  in  the  folds  of  the  fimbria',  and  on  palpation  small  nodules  can 
be  felt.  The  nodulai'  growth  has  evidently  involved  the  fimbria'  of  the  tube. 
The  tube  measures  4.5  x  3  x  2  cm.  It  is  covered  with  a  few  adhesions.  Be- 
tween the  tube  and  ovary  is  a  nodule  8  mm.  in  diameter.  This  is  sharply  cir- 
cumscribed, pearly  white,  and  translucent,  being  evidently  secondary  to  the  old 
growth.  Between  the  end  of  the  tube  and  the  ovary  is  a  smaller  nodule,  7  mm. 
in  diameter. 

Histologic  examination  shows  that  the  growth  is  a  sarcoma,  and  there  ap- 
pears to  be  a  transition  between  the  muscle-fibers  and  the  sarcoma.  It  is  im- 
possible to  determine  with  certainty  whether  it  was  primary  sarcoma  of  the 
uterus  or  whether  it  was  secondary  to  the  myoma. 

Gyn.  No.  11944.     Path.  No.  8350. 

Large  interstitial  a  ii  d  p  a  r  t  i  a  1  1  y  s  u  b  m  u  c  o  us  myoma. 
M  a  r  k  e  d  h  y  a  1  i  n  e  t  r  a  n  s  f  o  r  m  a  t  i  o  n  ,  with  1  i  (|  u  e  f  a  c  t  i  o  n  , 
and  u  n  d  e  r  going  s  a  r  c  o  m  a  t  o  u  s  t  r  a  n  s  f  o  r  m  a  t  i  0  n  .  N  0  r - 
m  a  1    t  u  1)  e   a  n  d    o  v  a  r  y  . 

R.  A.,  white,  aged  forty-six,  married.  Admitted  March  7:  discharged 
March  29,  1905.  The  patient  complains  of  an  abdominal  tumor.  She  has  had 
two  children  and  no  miscai'riages.  The  oldest  child  is  thirteen,  the  youngest,  ten. 
The  menses  began  at  sixteen,  and  at  first  were  regular  and  normal  in  amount. 
Since  the  birth  of  the  last  child,  ten  years  ago,  the  flow  has  been  excessive,  lasting 
as  long  as  eight  or  nine  days,  until  two  years  ago:  since  that  time  it  has  been  very 
scant,  and  tlie  periods  have  i)een  irregular.  At  times  she  has  had  no  flow  for 
four  or  five  months.  The  last  period  was  two  months  ago.  This  one  was  so  ex- 
cessive that  the  uterus  had  to  l)e  jiacked.  The  doctor  at  the  time  the  child  was 
born,  ten  years  ago,  noticed  a  tumor,  and  thought  at  first  that  it  was  a  second 
child.  This  tumor  increased  in  size,  and  six  years  later  she  was  treated  with 
electricity  and  the  tumor  ajiparently  became  smaller.     Since  ihv  hemorrhage  two 


MYOSARCOMA    OF    THE    UTERUS.  233 

months  ago  the  patient  has  remained  in  bed  on  account  of  weakness.  The  left 
leg  began  to  swell.     There  was  difhcult  and  j)ainful  urination. 

The  abdomen  was  distended  to  the  size  belonging  to  a  full-term  pregnancy. 
The  tumor  was  rather  soft  in  consistence.  It  rose  to  the  costal  border.  The 
uterine  vessels  were  very  large,  some  of  them  reaching  1  cm.  in  diameter.  The 
uterus  was  amputated  through  the  cervix.  The  ])atient  stood  the  operation  well. 
She  made  an  excellent  recovery,  and  was  discharged  March  29,  1905. 

Path.  No.  8350.  The  specimen  consists  of  a  greatly  enlarged  uterus,  which 
has  been  amputated  through  the  cervix.  It  is  25  cm.  in  length,  17  cm.  in  l)readth, 
and  16  cm.  in  its  anteroposterior  diameter.  It  is  perfectly  smooth  and  glistening. 
The  great  increase  in  size  of  the  uterus  is  due  to  the  presence  of  a  myoma,  20  cm. 
in  its  greatest  diameter.  This  myoma  on  section  is  edematous,  and  here  anfl  there 
shows  a  certain  amount  of  breaking  down,  presenting  a  tyi)ical  picture  of  a  myoma 
undergoing  diffuse  hyaline  degeneration  with  moderate  licjuefaction.  At  one 
point  is  an  irregular  cystic  space,  3x2  cm.  Its  walls  are  rather  ragged,  and  the 
appearance  suggests  a  breaking  down  of  myomatous  tissue.  At  several  points  are 
little  whitish  nodules,  rather  hard.  Such  areas  have  undergone  calcification.  The 
uterine  cavity  is  15  cm.  in  length.  The  nnicosa  is  smooth  and  glistening, but 
exceedingly  thin. 

On  histologic  examination  the  mucosa  of  the  liody  of  the  uterus  is  intact. 
The  surface  epithelium  is  ])erfectly  preserved.  The  glands  are  normal.  The 
mucosa  is  exceedingly  thin.  The  stroma  is  normal.  The  veins  in  the  mucosa  are 
here  and  there  much  dilated.  The  muscle  inmiediately  beneath  the  mucosals 
normal.  Then,  as  we  pass  directly  to  the  myoma,  a  marked  chang(»  is  noted. 
The  muscle  has  a  wild  appearance,  and  under  the  low  ])Ower  the  nuclei  are  en- 
larged and  stain  deeply.  These  deeply  staining  nuclei  sometimes  are  isolated; 
in  other  places  there  are  rows  of  three  or  four.  The  nuclei  also  occur  in  bunches 
of  four  or  five,  presenting  a  mulberry-shaped  ai)pearance.  These  nuclei  are 
three  or  four  times  the  normal  size,  and  stain  deeply.  Nearly  the  entire  central 
portion  of  the  myoma  has  undergone  C()m])lete  hyaline  transformation,  and  there 
is  also  liquefaction,  partial  or  c()ni{)lete.  In  ])lac("s  wlicre  the  luusclc-huiidlcs  are 
intact  one  also  notes  an  irregularity  in  the  size  of  the  iniclei,  many  of  whicii  are 
becoming  larger.  Far  out  in  the  hyaline  tissue  the  nmscle-bundles  here  and 
there  are  still  ])reserved.  Some  of  these  present  the  usual  ajipearance;  oth(>rs 
show  an  increase  in  size  of  the  iniclei,  and  auii'iueiitalion  in  amount  of  chroiiKitin. 
together  with  deep  staining.  At  one  j)oint  in  the  hyahne  tissue  one  sees  an  ex- 
(juisite  picture,  a  few  nmscle-fibers  ix'ing  ])reserve(l  aroimd  an  artery.  The  lumen 
of  the  artery  is  still  intact,  and  a  few  of  the  muscle-lihei-s  preseiU  ihe  iioiinal 
appearance,  but  those  a  short  distance  away  show  mni'keil  .•icti\ity.  Secti(tns 
were  cut  from  various  areas  cori'espotuhng  to  on'ci-  h;ilf  I  he  surhice  (»I  a  longitudinal 
section  of  thiMiiyoma.  The  same  |)icl  ui'e  is  note(l  in  neaily  :ill  ot  ihem.  Sections 
through  other  portions  of  the  niyoni;i  show  absolute  hy:iline  t  I'ansfoi'ination. 

\\v  have  hei'e  an    intersiiiinl   and    pari iall\' submucous   ni\-oma,  which   has 


234  MYOMATA    OF    THE    TTKRUS. 

undergone  almost  conipk'te  hyaline  triinsfoniiation.  The  myoma,  at  its  junc- 
tion with  the  normal  muscle,  has  undergone  sarcomatous  transformation.  The 
islands  of  myomatous  tissue  that  have  been  preserved  in  the  hyaline  areas  also 
show  similar  changes.  There  is  not  the  .slightest  doubt  that  the  sarcoma  is 
dev('l()|)iiig  from  a  myoma.  This  is  another  exam]:)le  of  the  predisposition  of 
myomala    that   liavc    uiKicrgoiic    marked    hyaline  changes   and  li(|U('faction  to 

beeonn'  sarcomatous. 

Gyn.  No.  1558.     Autopsy  No.  353. 

.Multiple  uterine  m  y  o  m  a  t  a  with  marked  sarcomat- 
ous implication  of  the  a  b  d  o  m  i  n  a  1  viscera  an  d 
1  y  m  ]>  h  -  g  1  a  n  d  s  . 

In  this  case  the  uterus  was  enormously  enlarged,  and  possibly  bore  a  causal 
relation  to  the  wide  distribution  of  sarcomatous  nodules.  Being  in  no  position, 
however,  to  prove  this,  we  have  placed  the  case  in  a  class  by  itself. 

M.  B.,  colored,  aged  thirty-eight,  married.  Admitted  September  10;  died 
October  1,  1892.  The  patient  has  never  been  pregnant.  Her  menses  com- 
menced at  fourteen  and  were  regular,  the  flow  lasting  from  five  to  six  days,  and 
accompanied  l\v  cram{>-like  pains.  The  flow  has  l)een  very  profuse  and  abun- 
dant. In  1S91  her  fri(>nds  noticed  that  her  abdomen  was  larger  than  usual, 
but  the  increase  in  size  had  been  painless.  She  has  lost  in  weight  since  March  of 
this  year,  and  is  very  short  of  breath.  The  abdomen  is  distended  from  the 
symphysis  to  the  xiphoid,  and  from  flank  to  flank.  It  is  globular  in  shape.  There 
is  an  umbilical  hernia,  3.5  x  3.5  cm.;  through  the  h(>mial  opening  hard  nodular 
masses  can  be  felt,  and  the  lower  ribs  are  lifted  up. 

The  patient  was  not  operated  upon,  l)ut  sank  ra{)idly  during  the  two  or  three 
days  preceding  her  death,  suffering  but  little  from  pain,  but  markedly  from 
dyspnea.  The  temperature  for  the  first  two  weeks  varied  between  normal  and 
100.7°  F.  for  two  days  prior  to  her  death,  later  between  95°  and  96.4°  F. 

A  u  t  o  [)  s  y  N  o  .  3  5  3  .  Anatomic  diagnosis  :  M  u  1 1  i  p  1  (^  u  t  e  r  - 
i  n  e  m  y  o  m  a  t  a  :  m  y  o  m  a  in  vaginal  wall;  c  o  m  p  r  e  s  s  i  o  n 
of  the  iliac  veins:  sarcoma  of  the  p  e  r  i  p  a  n  c  r  e  a  t  i  c  and 
mesenteric  1  y  m  }i  h  -  g  1  a  n  d  s  .  Secondary  sarcoma  of  the 
peritoneum,  o  m  e  n  t  u  m  ,  mesentery,  intestine,  stomach, 
liver,   p  1  e  u  r  x  ,   a  n  tl  lungs. 

Peritoneal  cavity;  Several  hundred  cubic  centimeters  of  yellow  fluid  were 
present.  When  the  abdomen  was  opened,  a  large  mass  was  found  occupying 
the  entire  jielvis  and  reaching  to  the  umbilicus.  It  was  nodular,  hard,  and  had  a 
.sulcus  corres])onding  to  the  median  line.  Smaller  nodules  were  distributed  over 
the  surface  of  the  tumor.  The  parietal  peritonemn  was  studded  with  nodules 
varying  from  1  to  6  nun.  or  more  in  size.  Some  of  them  were  coalescing.  Snn- 
ilar  nodules  \ver(>  ])resent  on  the  intestines  and  the  mesentery.  The  omentum 
was  greatly  distorted  and  thickened,  and  extended  to  the  lower  l)order  of  the 
umbilicus.     It  was  studded  with  similar  nodules,  grayish  white  in  color.     The 


MYOSAECOMA    OF    THK    ITKRUS.  235 

smaller  ones  were  somewhat  translucent.  The  omental  vessels  everywhere  were 
dilated  and  showed  extravasations.  The  liver  was  adherent  to  the  intestine 
and  to  the  abdominal  wall  in  the  median  line,  and  extended  8  cm.  below  the 
ensiform  cartilage.  The  whole  of  the  small  intestine  was  located  in  the  right 
hypogastric  region,  and  coagulated  serum  was  present  between  the  intestinal 
loops.  In  the  left  hypogastric  region  was  a  large  firm  mass,  adherent  to  the 
adjacent  structures. 

The  spleen  was  adherent  and  high  up.  At  the  site  of  the  left  kidney  was  a 
large  firm  nodular  mass.  The  lungs  were  not  adherent,  but  nodules  could  be 
felt  beneath  the  pleura^.  The  uterus  was  enormously  and  symmetrically  en- 
larged. The  left  side  was  more  prominent  than  the  right.  The  ])eritoneal 
surfaces  were  studded  with  nodules,  similar  to  those  above  mentioned.  Large 
confluent  nodular  masses  covered  the  floor  and  sides  of  the  cul-de-sac.  On  the 
right  side  and  anterior  to  the  uterus  was  a  globular  mass,  about  the  size  of  an 
orange,  markedly  constricted  at  its  point  of  attachment.  On  section,  it  was 
dense  and  presented  the  usual  myomatous  picture.  Above  and  to  the  right  of 
it  a  second  and  similar  tumor,  the  size  of  a  walnut,  was  present.  On  the  left, 
over  the  posterior  surface,  were  some  six  or  eight  other  subperitoneal  nodules, 
the  smaller  ones  measuring  about  a  centimeter,  the  larger  the  size  of  a  walnut. 
On  section,  the  walls  of  the  uterus,  which  was  greatly  hypertrophied,  were  found 
to  contain  numerous  myomata  of  various  sizes.  Submucous  myomata  were 
also  present. 

Vaginal  myoma:  In  the  posterior  wall  of  the  vagina,  embedded  in  loose  tissue 
and  not  adherent  to  the  wall,  was  a  myoma,  4x2  cm.  This  tumor  was  shelled 
out  without  difficulty. 

Mesenteric  tumor:  A  tumor,  weighing  2800  gm.  and  measuring  23  x  9  x  13 
cm.,  occu])ied  the  left  up])er  abdominal  quadrant  and  was  ])ressing  down  upon 
the  left  kidney.  It  was  separated  from  the  surrounding  structures  with  ditliculty. 
It  appeared  to  be  retroperitoneal.  It  was  firmly  attached  behind,  and  sprang 
apparently  from  glands  about  the  pancreas.  It  was  encased  in  a  thin  capsule, 
from  which  it  could  be  stripped.  It  was  irregularly  nodular,  and  on  its  outer 
surface  were  grayish  trabecuhe.  On  section,  it  appeared  homogeneous,  ex- 
cepting where  large  areas  of  coagulation  necrosis  and  hemorrhage^  were  present. 
Firmly  adherent  to  the  upj)er  suii'ace  of  this  tunioi-  was  a  second  (Hic.  measuring 
22  x  12.5  X  10  cm.,  and  weighing  1200  gm.  It  i»fcscnte(l  ;in  appcai-ance  simiiai' 
to  that  of  the  tumor  described. 

Metastases  were  found  in  the  walls  of  the  stomach  and  intestines,  in  the 
liver,  pleura',  hmgs,  and  mesentery. 

Histologic  examinaticjn  showed  that  t  he  ret  roperitoneal  growth  was  a  sarcoma. 
There  is  no  mention  as  to  the  probable  origin  of  this  retroperitoneal  growth.  ( )n 
microscopic  e.xamination  of  the  uterus  it  looked  \-ery  much  as  if  we  had  two  in- 
dependent processes,  a  retroperitoneal  sarcoma  ami  mnnerous  subperitoneal, 
interstitial,  and  sul)nuicous  uterine  rn\-omata. 


236  MVO.MATA    OF    THK    UTERUS. 


Myomat A  Presenting  Gross  or  Histologic  Appearances  Suggestive  of  Sarcomatous 

Degeneration. 

In  the  foregoing  ])ag('s  we  have  dealt  with  inyoiiiata  sliowing  iindouhted 
sarcomatous  changes,  ^^'e  will  now  review  several  cases  in  which  the  inyoinata 
show  alterations  somewhat  suggestive  of  sarcomata,  changes,  however,  that  are 
not  sufHciently  conclusive  to  wari'ant  a  positive  diagnosis  of  malignancy.  Some- 
times the  gross  appearance  of  the  myoma  suggests  a  sarcomatous  change,  hut  in 
the  majority  of  these  the  growth  will  present  the  typical  myomatous  picture,  and 
only  on  careful  histologic  study  will  any  evidence  of  sarcoma  be  found. 

Sometimes  it  is  particularly  difficult  to  determine  whether  a  given  specimen 
really  shows  sarcomatous  changes  or  not.  We  have  had  seventeen  cases  in  which 
the  growth,  either  in  the  gross  or  microscopically,  ])resented  alterations  that 
strongly  suggested  a  malignant  condition,  but  in  which  the  changes  were  not 
sufficiently  marked  to  enable  us  to  say  with  certainty  that  they  were  sarcomatous. 
These  border-line  cases  are  of  especial  interest  to  the  ])athologist,  and  we  ac- 
cordingly give  the  salient  features  in  each  case. 

For  convenience  these  cases  can  be  divided  into  two  groups: 

(1)  Those  showing  gross  appearances  strongly  suspicious  of  .sarcoma. 

(2)  Those  in  which  the  histologic  picture  is  suggestive  of  sarcoma. 

Of  course,  some  of  the  cases  show  both  gross  and  histologic  changes  strongly 
indicative  of  malignancy. 

Cases  in  which  the  Gross  Appearances  of  the  Tumor  Suggested  Sarcoma. 

The  myoma  in  Case  127S8,  although  small,  was  markedly  lobulated,  pre- 
sented a  mottled  a])])earance,  and  might  have  been  readily  mistaken  for  sarcoma. 
As  soon  as  it  was  touched,  however,  all  doubt  was  dispelled,  as  the  character- 
istic density  of  myomatous  tissue  was  everywhere  in  evidence. 

In  Case  8477  a  nodule,  2  cm.  in  diameter,  projecting  from  a  large  myoma, 
was  so  soft  that  sarcoma  was  at  once  suspected.  So  firmly  convinced  was  the 
operator  that  he  was  dealing  with  a  sarcoma  that  a  comjilete  hysterectomy  was 
performed. 

In  Ca.se  12864  the  tumor  at  ojK'ration  was  found  to  l)e  very  soft;  moreover, 
it  bled  easily  and  felt  like  sarcoma.  This  softening  was  due  chiefly  to  cystic  and 
hyaline  changes.  In  certain  areas  the  ca))illaries  were  so  abundant,  and  their 
endothelium  had  so  proliferated,  that  the  tissue  was  divided  up  into  myriads  of 
alveoli,  at  first  glance  strongly  suggesting  a  malignant  growth. 

In  Fig.  156  (p.  238)  we  have  a  large  subperitoneal  myoma  springing  from  the 
I)osterior  surface  of  the  uterus,  and  attached  to  it  by  a  Inroad  pedicle.  One  is 
instantly  struck  by  the  unu.sual  ap))earance,  the  growth  ])resenting  a  mark(>dly  lob- 
ulated form,  welling  uj),  as  it  were,  on  all  sid(>s  of  the  j)edicle.  Agani,at  c  and  d  are 
represented  clumps  of  small  flat  papillary  outgrowths.  From  the  pathologic 
re))ort  we  learn  that  the  surface  of  the  growth  was  verv  vascular.     Thus  far  the 


MYOSARCOMA    OF    THE    ITKRUS.  237 

growth  bears  a  striking  resemblance  to  a  malignant  growth,  as  only  exceptionally 
do  we  find  such  a  welling-out  of  tissue  on  all  sides;  and,  further,  in  benign  myo- 
mata  such  papillary  masses  as  are  seen  at  c  and  d  are  rarely  ev(u-  noted.  On 
section,  the  growth  was  found  to  be  in  part  solid,  in  part  cystic.  Its  cut  surface 
resembled  that  of  a  myoma.  On  histologic  examination,  in  general  it  presented 
the  appearance  of  a  simple  myoma,  but  in  places  the  cells  were  very  abundant 
and  closely  packed  together.  Furthermore,  a  few  nuclear  figures  were  found. 
Both  these  findings  suggest  to  a  slight  degree  sarcoma,  but  there  was  marked 
uniformity  in  the  size  of  the  nuclei.  In  this  case,  although  sarcomatous  degenera- 
tion cannot  be  positively  excluded,  the  weight  of  evidence  is  in  favor  of  a  rapidly 
growing  but  benign  myoma.  Fig.  157  (p.  241)  represents  half  of  a  uterus  which 
shows  a  diffuse  myomatous  thickening.  At  c  we  have  a  small,  well-defined  sub- 
mucous myoma;  at  d,  two  minute  myomata,  and  at  e  a  partially  pedunculated 
submucous  myoma.  This  pedunculated  submucous  nodule  is  the  one  of  chief 
interest.  The  mucosa  over  it  is  everywhere  intact.  The  nodule  near  its  base 
shows  remains  of  the  muscle-bundles,  but  in  the  upper  portion  and  near  the  tip 
the  tissue  presents  a  homogeneous  appearance,  all  trace  of  fibers  having  disa])- 
peared.  This  homogeneity,  coupled  with  the  softness  of  the  growth,  instantly 
arouses  one's  suspicions  of  a  malignant  growth,  and  as  the  mucosa  covering  it  is 
intact  and  somewhat  atrophic,  the  most  natural  supposition  is  that  the  myoma 
is  undergoing  sarcomatous  changes,  which,  however,  are  very  early. 

The  histologic  appearances  of  this  submucous  nodule,  as  seen  in  Fig.  158 
(p.  242)  and  Fig.  159  (p.  243),  are  even  more  suggestive  of  sarcoma.  In  Fig.  158 
the  appearance  of  ''unrest"  is  manifest.  Here  in  places  the  cells  are  more 
closely  packed ;  in  another  place  one  cell  may  contain  two  nuclei,  while  in  the 
neighborhood  may  be  a  cell  containing  five  or  six  nuclei.  Some  of  the  nuclei 
contain  an  increased  amount  of  chromatin.  In  Figs.  159  and  161  the  changes 
are  still  more  marked.  Here  we  have  ill-defined  giant-cells  and  large,  iiTcgulai-. 
deeply  staining  nuclei,  containing  hyaline  droplets.  Polym()r])h()nuclear  leu- 
kocytes and  small  round  cells  are  also  scattered  throughout  the  field.  In  fig. 
160,  while  the  same  changes  are  to  be  noted,  v(mt  large  and  irregular  clumps  of 
chromatin  are  seen  lying  in  hyaline  tissue.  In  this  case  both  the  gross  ar.d 
histologic  pictures  are  very  suggestive  of  sarcomatous  degeneration  of  the  myoma. 
If  a  malignant  change  is  present,  it  is  still  in  its  infancy,  as  the  growth  is  small. 
well  defined,  and  has  not  pushcnl  its  way  thi-ough  the  thin  ovei'lying  layer  of 
mucosa.  We  can  i-eadily  understand  how  a  sarcoma  may  develop  in  such  a 
snail  myoma,  and  how,  in  the  course  of  a  few  months,  all  trace  of  the  originrd 
myomatous  tissue  may  be  obliterated. 

Gyn.  No.  91 18.     Path.  No.  5274. 

A  large  in  y  o  m  a  t  o  u  s  u  I  e  r  u  s  w  i  t  h  m  y  o  in  a  t  o  u  s  t  i  s  s  u  e 
w  e  1  1  i  n  g  out  f  r  o  111  t  h  e  u  t  e  r  u  s  ,  a  11  d  p  r  e  s  e  n  t  i  n  g  a  p  i  c  t  u  r  e 
m  a  c  r  0  s  c  o  p  i  c  a  1  1  y    suggest  i  v  v    of    sarcoma    ( I''ig.   156). 


238 


.MYO.MATA    Ul"    THE    ITKRl'S. 


E.  S.,  white,  aged  r()rty-('i<i;ht.  Admitted  O.-'tohcr  10;  discharged  Novem- 
ber 8,  1901.  The  patient  eotiiplains  of  an  aixloniirial  tuiiinr.  The  menses  com- 
menced at  eh'X'en  and  were  I'eu'ular:  the  flow  was  scanty  in  amount.  Since  the 
onset  of  the  present  tiouhle  the  How  has  histe<l  one  week,  hut  tliere  has  been  no 
excessive  bU'cchng.     There  has  been  a  (Hscharge   with  a   \'er\-  offensive  odor. 


Fig.  156. — .\  Rapidly  Gkowi.ng  SrBPEniTo.\E.\L   Myo.m.\  with  S.mam,,  1'apill.e-Likk  Ovtgrowths  Spri.n(;ixg 

FROM  iT.s  SuRFACK.  (1  nat..size.) 
Path.  No.  .5274.  The  uterus  i.s  relatively  normal  in  .size,  and  the  tube.s  and  ovarie.s  pre.sent  the  ii<ual  appear- 
ance. Springing  from  the  fundus  by  a  broad  pedicle,  a,  i.s  a  very  large  subperitoneal  myoma.  This  tuiuor,  instead 
of  being  smooth  and  globular,  wells  up  on  all  sides  of  the  pedicle,  leaving  here  and  there  deep  clefts  where  the 
connective  ti.ssue  has  been  particularly  dense,  b  is  a  flattened  myomatous  nodule  lying  on  the  surface  of  the 
large  growth.  At  c,  d,  and  e  are  flatteneil,  pai)ill;o-likc  outgrowtlis  of  myoniatous  ti.ssue.  A  myoma  presenting 
such  a  picture  is  rarely  seen. 

The  patient  has  been  married  twenty-eight  years  and  has  liad  two  chiMreii.  She 
first  noticed  a  mass  in  the  ligiit  side  .seven  years  ago.  This  has  grown  stea(hly 
hirger  and  caused  pain  in  the  right  si<le;  otherwise  she  feels  well.  Hemoglobin, 
75  per  cent. 

Operation.     The  pedicle  attaching  the  tumor  to  the  uterus  was  fii-st  cut.  the 
tumor  being  then  se])arate(l  from  the  uterus.     The  tumor  having  been  bisected, 


MYOSARCOMA    OF    THE    UTKRUS.  239 

the  left  half  was  removed,  and  later  the  right.     This  bisection  was  done  on  ac- 
count of  adhesions.     The  patient  made  a  very  satisfactory  recovery. 

Path.  No.  5274.  The  tumor  is  oval  in  shape,  and  measures  22  x  10  x  16  cm. 
It  was  attached  to  the  posterior  part  of  the  left  side  of  the  uterus.  It  was  densely 
adherent  to  the  rectum  and  to  surrounding  tissue.  The  tumor  as  a  whole  is 
bluish  gray  in  color,  and  on  first  inspection  reminds  one  of  an  ovarian  cyst. 
It  is  irregularly  lobulated,  and  springing  from  the  surface  are  numerous  papillae- 
like  outgrowths.  Their  presence  is  explained  by  the  fact  that  the  tumor  sub- 
stance has  grown  too  rapidly  for  the  capsule,  and  hence  has  welled  out,  produc- 
ing these  papillary  masses  (Fig.  156).  They  vary  from  the  size  of  a  pea  to  4  cm. 
in  diameter.  The  outer  surface  of  the  tumor  is  very  vascular.  On  section,  the 
portion  nearest  the  pedicle  has  the  appearance  of  a  soft  myoma.  The  remaining 
half  has  been  converted  into  a  thin- walled  cyst.  Traversing  this  cyst  are  numer- 
ous trabecuke  stretching  from  side  to  side.  The  cyst  contents  are  l)lo()(ly  in 
character. 

Histologic  Examination. — The  growth  in  general  presents  the  appearance 
of  a  myoma.  In  many  places,  however,  there  is  nuich  hyaline  degeneration. 
At  other  points  the  entire  field  is  filled  with  muscle-cells  lying  in  such  close  re- 
lationship to  one  another  as  to  give  an  indefinite  suggestion  of  sarcoma.  A  few 
nuclear  figures  are  here  and  there  seen,  but  there  is  a  marked  unifornnty  in  the 
size  of  the  nuclei.  The  large,  irregular,  cyst-like  spaces  are  due  to  a  breaking- 
do^^Tl  of  the  tumor,  as  its  walls  have  no  epithelial  lining,  but  are  composed  of 
hyaline  tissue.  There  are  also  other  smaller  areas  of  liquefaction.  The  growth 
is  a  myoma  undergoing  hyaline  degeneration.  We  do  not  think  that  thcTe  is 
any  sarcomatous  change,  although  the  possiljility  cannot  be  excluded  in  view 
of  the  fact  that  nuclear  figures  are  scattered  throughout  the  myoma,  a  condition 
that  is  most  unusual. 

Sub.sequent  history,  Nov(>mber  24,  1902:  Dr.  Alexander  Hannah  writes  that 
the  patient  feels  quite  well — better  than  she  has  been  for  twenty  years,  and  is 
able  to  do  all  her  own  housework. 

January,  1907:  This  y:)atient  is  in  excellent  health  five  years  and  four  months 
after  operation. 

Gyn.  No,  12864.     Path.  No.  10311. 

A  V  e  r  y  large  m  u  1  t  i  n  o  d  u  1  a  r  m  y  o  m  a  I  o  u  s  u  t  e  r  u  s  w  h  i  c  li 
a  t  o  p  e  r  a  t  i  o  n  w  as  so  soft  and  b  1  e  il  so  f  r  e  e  1  y  that  t  h  e 
c  o  n  d  i  t  i  o  n    w  a  s    s  t  r  o  n  g  1  y   suggestive   of   s  a  r  c  o  m  a  . 

M.  B.,  colored,  aged  forty-four,  married.  Admitted  A))ril  21  :  discharged 
May  23,  1906.  Her  menses  commenced  at  thirteen,  occurred  every  four  weeks, 
and  were  usually  ratlier  ])rofuse.  The  last  period  caine  on  one  month  befoic 
admission.  She  has  been  man-ieil  t\venty-se\'en  \('ars.  luul  one  child  twenty- 
six  years  ago,  and  no  miseai-riages.  Swelling  of  the  abdomen  was  first  noticed 
fifteen  years  ago.  The  patient  thought  she  was  pregnant,  but  the  menses  did 
not  cease,  and  there  was  no   ])ain.      The  growth   increased  slowly,  and  scn'en 


240  MVO.MATA    OK    THK    ITKRIS. 

yenirs  later  her  physician  told  her  she  had  a  niyuiiia,  but  advised  against  opera- 
tion. The  swelling  has  steadily  increased  in  size.  For  the  past  five  months 
there  has  been  pain  in  the  lower  i)ack,  and  bearing-down  pains  in  the  abdomen 
after  exertion.  For  the  last  three  months  the  tumor  has  grown  ([uite  rapidly, 
and  the  ))ain  in  the  abdomen  and  l)ack  has  been  severe  at  times.  For  the  last 
four  oi"  five  days  she  has  had  diliiculty  in  micturition. 

Operation.  The  omentum  was  densely  adherent  to  the  tumor.  In  lifting 
up  the  tumor  it  was  found  firmly  adherent  in  the  pelvis.  It  was  very  soft,  bled 
easily,  contained  cystic  areas,  and  was  very  suggestive  of  sarcoma.  It  was 
impossil)le  to  get  a  .satisfactory  e\{)osure,  and  in  dissecting  on  the  left  side  an 
opening  was  made  into  the  bladder,  which  had  l)een  lifted  high  up  and  pushed 
forward  by  a  retrovesical  nodule.  After  considerable  difficulty  the  tumor  was 
entirely  removed.  The  patient  was  catheterized  in  all  o<S  times.  She  made  a 
very  satisfactory  recovery. 

Path.  No.  10311.  The  specimen  consists  of  a  large  multinodular  myomatous 
uterus,  28  x  25  x  20  cm.  The  omentum  is  densely  adherent  to  one  of  the  large 
nodules.  The  myomata  have  undergone  hyaline  degeneratioji.  and  several 
contain  areas  of  calcification  along  their  edges.  The  uterine  cavity  is  distorted, 
and  the  mucosa  is  scant  in  amount.  The  tubes  and  ovaries  are  normal  save 
for  a  small  cyst,  6x4x4  cm. 

Histologic  examination  shows  a  myomatous  uterus  with  definite  hyaline 
areas.  Along  certain  parts  of  the  myoma  the  entlothelium  (jf  the  capillaries  has 
proliferated  to  such  an  extent  that  the  nmscle-fibers  are  divided  off  into  alveoli 
which  one  might  very  I'eadily  think  l)elonged  to  a  malignant  growth. 

San.  No.  471.     Path.  No.  1815. 

A  s  u  b  m  u  c  o  u  s  m  y  o  m  a  p  r  e  s  e  n  t  i  n  g  a  h  o  m  o  g  e  n  e  o  u  s 
a  p  p  e  a  r  a  n  c  e  and  suggesting  s  a  r  c  o  m  a  (Fig.  157).  His- 
tologic changes  suggestive  o  f  s  a  r  c  o  m  a  (Figs.  158,  159, 
160,    161). 

D.  C.  ('.,  white,  aged  forty-four,  mai'ried.  Admitted  May  22;  discharged 
June  30,  1897.  Complaint,  uterine  hemorrhages.  The  patient  has  been  married 
ten  years,  has  had  one  child  and  no  mi.scarriages.  A  year  ago  the  periods  be- 
came prolonged,  lasting  eight  days,  and  the  flow  was  more  profuse.  The  patient 
has  lost  a  great  deal  of  blood.  Opei'ation,  May  25.  1S97.  Alxlominal  hyster- 
ectomy. The  highest  p()sto])erative  lempei-ature  was  101°.  The  patient 
made  a  good  recovery. 

Path.  No.  1815.  The  specimen  com])i'is('s  the  uterus,  tubes,  and  ovaries 
intact.  The  uterus  measures  11  cm.  in  length.  S  cm.  in  bi-cadth,  and  5  cm.  in 
its  anteroposterior  diameter  (Fig.  157).  Its  peritoneal  surface  is  smooth.  The 
cervix  presents  a  nodular  appearance  when  viewed  from  below,  but  the  mucosa 
lining  the  canal  has  mimUe  piickles  s))ringing  from  its  surface.  The  uterine 
cavity  is  4.5  cm.  in  length.      Its  mucosa  is  vcrv  thin,  but  has  a  .smooth,  intact 


MYOSARCOMA    OF    THK    UTKRUS, 


241 


surface.  The  anterior  uterine  wall  varies  from  2  to  3  cm.  in  thickness,  the  pos- 
terior from  2.5  to  4  cm.  Occupying  the  fundus  and  projecting  into  the  uterine 
cavity  are  two  myomata.  One  is  circular,  2.5  cm.  in  diameter,  and  ])resents  the 
typical  myomatous  picture.     The  second  nodule  is  somewhat  ])ear-shaped,  and 


Fig.  157. — Diffuse  Myomatous  Thickenixo  of  the  Uterine  Wall.  Discrete  Submitous  Myoma  axd  a 
Submucous  Myoma  PRKSENTiNt;  an  Appearance  Suggestive  of  Sarcoma.  (Nat.  size.) 
Path.  No.  1815.  The  ijictuie  represents  a  longitudinal  section  through  the  uterus.  The  uterine  cavity,  as 
seen  at  a,  is  slightly  enlarged.  The  mucosa  is  somewhat  atroi)hic.  At  a'  the  upper  part  of  the  uterine  cavity 
is  seen,  b  is  the  diffusely  thickened  uterine  wall.  At  c  is  a  typical  submucous  myoma,  d  also  indicates  two 
similar,  but  much  smaller,  nodules,  e  is  a  pedunculated  submucous  myoma.  Near  its  bivse  the  strands  of  muscle 
are  clearly  in  evidence,  but  toward  the  tip  the  tissue  is  homogeneous  and  the  fibrillation  is  lacking.  This  homo- 
geneity is  most  unusual,  and  makes  one  instantly  suspicious  of  a  malignant  change.  For  the  histologic  apjiear- 
ances  see  Figs.  1.58,  159,  IGO,  and  ItU. 


measures  3  cm.  in  Iciigtli  and  2  cm.  in  hrc.-idlli.  il  is  pcdunciilntcil  niid  pi-ojccts 
far  down  into  the  uterine  caN'ity.  Il  hcni's  some  rrscniMancc  to  ;i  myoma,  hut 
the  coarse  striation  is  ladling  and  the  tissnc  apjx'ars  sonicwliat  lioiiiogciicous. 
This  nodule  is  covered  with  an  intact  mucosa,  wiiicli  is,  liowcxcr.  not  more  than 
0.5  mm.  in  thickness.  The  tuhcs  and  ox'arics  arc  normal. 
H) 


242 


MVO.MATA    OF    TIIK    ITKIU'S. 


C 


Histologic  Exauiiniition. — Sections  from  the  cervix  show  that  the  vaginal 
portion  is  normal,  and  that  the  cylindric  epithelium  of  the  cervix,  as  well  as 
that  of  the  cervical  glands,  presents  the  usual  appearance.  The  delicate  out- 
growths seen  springing  from  the  surface  of  the  cervix  are  papillary  masses  of 
stroma  covered  by  a  layer  of  cylindric  epithelium  continuous  with  that  of  the 
mucosa  proper.  They  are  in  no  way  suspicious.  The  mucosa  of  the  body  of  the 
uterus  has  an  intact  surface  epithelium.  Its  glands  in  a  few  places  show  hyper- 
trophy, l)Ut,  as  a  rule,  are  little  altered.  The  stroma  of  the  nmcosa  in  the  super- 
ficial jiortion  contains  a  few  small  round  cells  scattered  between  the  stroma  cells. 
The  pedunculated,  submucous  nodule  springing  from  the  fundus  consists 
in    part    of   typical    myomatous   tissue,   which  here  and  there  has  undergone 

complete  hyaline  degeneration.  Along  the 
margins  of  such  hyaline  areas  there  is  fre- 
([uently  a  deposition  of  orange-yellow  pig- 
ment droplets,  presumably  the  remains  of 
old  hemorrhages.  In  other  portions  of  this 
small  submucous  myoma  the  tissue  is  rarefied 
or  contains  large  areas  of  hemorrhage.  At 
still  other  points  all  trace  of  the  myomatous 
tissue  is  lost,  and  the  nuclei,  instead  of  being 
elongated,  oval  and  regular  in  size,  are 
plumper  and  vary  greatly  in  diameter.  .Some 
of  them  contain  round  or  oval  tran.slucent 
Path.  No.  181.5.   The  section  is  from  the     l)odies,  and  uuclci  fivc  or  six  times  the  usual 

suspicious  nodule  e  in  Fig.  157.    On  glancing  .                            . 

at  the  picture  one  is  instantly  impressed  with  SlZC,      SOUlCWhat       HTegular      lU      OUtlUie,      aud 
the  appearance  of  unrest,  and  is  reminded  of  ^^.^ij^jj^p.    j-^ther    dccplv.       Again,    foUr    Or    flvC 
sarcoma.     At  a  is  a  cell  containing  two  nuclei;  '-'                                 i    .^               o          ' 
at  b  is  an  aggregation  of   nuclei  forming  an  nUclci     may    fomi     OnC    cluiUp,     Jll'oducing    ill- 
ill-defined  giant-cell.      Scattered   throughout  i    /•         i         •        ,         ii             tt                      i      j.u 

the  field  are  several  deeply  staining  nuclei,     dehued   giant-cclls.      Here    and   thcrc  IS  an 

The  tissue  is  freely  infiltrated  with  .mall  r.mnd        inVgular,  VCrV  dccplv  Staiuiug  nUcleUS.      Such 
cells.  o  ..  I     . 

areas  as  the  ones  just  described  bear  a  striking 
resemblance  to  those  seen  in  sarcoma.  Given  such  a  picture  alone,  we  would 
not  hesitate  to  make  a  diagnosis  of  sarcoma.  Having  the  gross  specimen  before 
us,  however,  with  its  still  well-defined  outline,  we  hesitate  to  speak  of  it  as  a 
malignant  growth.  We  are,  however,  inclined  to  believe  that  there  is  a  com- 
mencing sarcomatous  degeneration. 

The  histologic  changes  are  well  depicted  in  Figs.  158,  159,  160,  and  161. 

Subsecjuent  History. — The  patient  writes  in  1902,  that  is,  about  five  years 
after  operation:  ''The  year  immediately  following  the  operation  I  was  in  fairly 
good  condition,  but  at  the  expiration  of  that  year  I  began  to  lose  strength  and 
flesh,  and  for  three  years  was  in  a  most  horribly  nervous  condition,  unable  to 
sleep  most  of  the  time  without  trional,  and  suffering  constantly  from  intestinal 
indigestion.  I  am  seemingly  better  this  fall  than  I  have  been  at  any  time  since 
the  operation." 


Fig.    158. — Suggestion    ok    S.\rcoma    in   . 
S.MALL  Submucous  Myom.\.    (X  145  diain.) 


MYOSARCOMA    OF   THE    UTKRUS.  243 

Gyn.  No.  12788.     Path.  No.  9662. 

Interstitial  and  s  vi  Ij  ni  u  c  o  u  s  u  t  c  r  i  n  c  ni  y  o  ni  a  t  a  .  One 
of  the  ni  y  o  ni  a  t  a  on  section  present  s  a  n  a  })  p  e  a  r  a  n  c  e 
that  might  readily  be  mistaken  for  s  a  r  c  o  m  a  . 

J.  D.,  white,  aged  forty,  married.  Admitted  March  21;  discharged  April  26, 
1906.  Her  mother  died  at  the  age  of  fifty-two,  supposedly  from  uterine  myo- 
mata,  and  two  sisters  were  operated  upon  for  myomata;  both  recovered.  The 
patient  at  times  has  swelling  of  the  feet  and  also  shortness  of  breath.  A  year  ago 
(Gyn.  No.  11700)  she  entered  the  hospital  and  was  treated  for  cystitis.  Her 
menses  began  at  sixteen,  were  profuse,  and  lasted  from  six  to  seven  days.     There 


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Fig.  159  Fig.  160.  Vi<:.  Itil. 

Suspicious  Cell  Changes  in  a  Small  Submucous  Myoma.     (X  150  diam.) 

Fig.  159. — Path.  No.  1815.  The  section  is  from  the  suspicious  submucous  myoma  (e)  in  Fig.  157.  a  is  a 
small  giant-cell.  At  b  the  nuclei  of  the  muscle-fibers  show  a  tendency  to  cluniping;  at  c  are  two  large,  irregular, 
and  rather  deeply  staining  nuclei,  suspicious  in  character.  There  is  considerable  sniall-round-celled  infiltration, 
as  indicated  by  d. 

Fig.  160. — Path.  No.  1815.  This  field  is  from  the  nodule  (e)  in  Fig.  157,  and  shows  hyaline  degeneration,  pro- 
nounced at  (a).  The  two  large,  irregular,  and  deeply  staining  nuclei  at  b  are  most  suggestive  of  a  malignant 
change.     The  nuclei  tend  to  form  clumps  (c).     Scattered  throughout  the  field  are  numerous  small  round  cells. 

Fig.  161. — Path.  No.  1815.  This  section  is  also  from  the  submucous  nodule  in  Fig.  157.  a  and  b  show 
clumping  of  the  nuclei,  which  correspond  exactly  in  size  and  shape  with  tho.se  of  the  surrounding  muscle-fibers, 
c  is  a  very  large  irregular  and  deeply  staining  nucleus,  containing  two  hyaline  droplets  and  very  suggestive  of  a 
commencing  sarcomatous  change.     The  tissue  shows  some  small- round-celled  infiltration. 

never  has  been  any  interinenstrual  bleeding  until  four  week.-;  ago.  The  jKiticnt 
has  been  married  twenty-two  years,  but  has  never  been  pregnant.  The  prc.-^cnt 
trouble  began  four  weeks  ago,  when  she  had  profuse  bleeding,  with  severe  pain 
in  both  sides  and  in  the  back.  The  bleeding  was  exc(>ssive,  and  large  clots  came 
away.  She  first  noticed  swelling  of  the  abdomen  one  month  ago,  and  thought 
that  she  was  getting  stout .     llcinoglobin,  70  percent. 

Operation.  Hysteromyomectomy  with  removal  of  adherent  appendages. 
The  patient  made  a  satisfactory  recovery.  Her  highest  postoperative  tenijH'r- 
ature  was  101.5°  F.,  on  the  second  day. 

Path.  No.  9662.  The  speeimen  consists  of  the  uterus  amputated  through  the 
cervix.     It  is  ajiproximatc^ly  9  em.  in  Icmgtii,  S  em.  in  l)readth,  and  7  em.  in  its 


244  :\IY().MATA    OF   THK    UTERUS. 

anteroposterior  diaiiu'tcr.  Posteriorly  it  is  eovt-rrd  by  a  few  adhesions.  Sit- 
uated in  the  fundus  is  a  markedly  lohulatcd  myoma,  3  cm.  in  diameter.  This, 
on  section,  has  a  mottled  ai)i)earance,  due  to  the  presence  of  large  and  small 
bundles,  and  might  very  readily  be  mistaken  for  sarcoma.  It  proves,  however, 
to  be  exceedingly  hanl.  Occu))ying  the  ))osterior  wall  and  jjrojecting  markedly 
into  the  cavity  is  a  submucous  myoma,  3.5  cm.  in  diameter.  The  uterine  mucosa 
is  very  atrophic  throughout  the  entire  cavity.  The  right  tube  is  covered  with 
a  few  delicate  adhesions.  The  ovary  is  exceedingly  small.  The  left  tube  is 
thickened  and  has  a  patent  fiml)riated  extremity.  The  ovary  has  apparently 
been  slightly  adherent. 

Histologic  Examination. — The  endometrium  is  to  a  great  extent  devoid  of 
an  epithelial  covering.  The  glands  are  few  and  far  between.  The  stroma  of  the 
mucosa  shows  considerable  small-round-celled  infiltration.  There  has  evidently 
been  a  mild  grade  of  endometritis.  Over  the  submucous  myoma  the  mucosa  has 
almost  entirely  disa])peared,  and  we  have  a  zone  of  marked  small-round-celled 
infiltration. 

The  gross  appearance  in  this  case  was  at  first  very  suggestive  of  sarcoma. 
From  a  clinical  standpoint  the  case  is  particularly  interesting,  as  the  patient's 
mother  presumably  died  of  myoma  and  as  the  patient's  two  sisters  were  operated 
upon  for  uterine  myomata. 

Gyn.  No.  8477.     Path.  No.  4672. 

P  a  n  h  y  s  t  e  r  e  c  t  o  m  y  instead  of  supravaginal  h  y  s  t  e  r  - 
e  c  t  o  m  y  o  n  ace  o  u  n  t  of  a  suspicious  s  u  b  peritoneal 
m  y  o  m  a  . 

E.  L.,  white,  agetl  forty-nine.  Admitted  .January  26:  discharged  February 
21.  1001.  Complaint,  soreness  and  sharp  pain  in  the  lower  abdomen.  Her 
menses  Ix'gan  at  fourteen  and  were  perfectly  regular.  The  menopause  occurred 
thirteen  months  ago.  She  has  had  no  hemorrhage  since  then.  She  has  been 
married  thirty-one  yeai's,  has  had  eight  children  and  two  miscarriages.  Two 
weeks  ago  the  patient  was  suddenly  taken  with  pain  and  burning  in  the  bladder 
region,  and  for  a  short  time  had  marked  frequenc}^  of  urination  accompanied  by 
nuich  ])ain.  After  seventy-two  hours  the  dysuria  practically  disa])peared,  and 
the  day  following  the  ))atient  had  some  soreness  in  the  up])er  right  side.  Her 
temjH'rature  at  this  time  rose  to  101.')°  F. 

Operation.  Hysteromyomectomy  performed  in  the  usual  manner;  the 
perineum  was  also  repaired.  An  abdominal  incision  having  been  made  and  the 
uterus  brought  up,  a  conical  sub])eritoneal  myoma  was  felt.  On  the  tip  of  this 
myoma,  which  was  the  size  of  an  orange,  was  a  rounded  i)rojection  2  cm.  in 
diameter,  and  .softer  in  consistence  than  the  myoma.  This  apparently  was  a 
small  sarcoma,  and  on  this  account  comjjlete  hysterectomy  was  performed. 
The  patient  made  an  uninterrui)ted  recovery. 

Path.  No.  4672.     The  specimen  consists  of  the  uterus.     From  the  posterior 


MYOSARCOMA    OF   THF:    UTERUS.  245 

surface  a  myoma  has  developed.  The  uterus  measures  6x7x4  cm.,  and  is  of 
the  normal  consistence.  Developing  from  the  upper  ]iosterior  wall  of  the  fundus 
is  a  tumor  6x6.  It  is  soft  and  almost  fluctuatino;.  It  is  covered  with  smooth 
peritoneum.  The  cut  surface  is  succulent  and  resembles  a  soft  myoma.  The 
uterine  cavity  is  4  cm.  in  length  and  4  cm.  in  breadth  at  the  fundus.  The  mucosa 
is  smooth  and  normal  in  appearance.  In  the  median  line  of  the  fundus  is  a 
sessile  polyp  measuring  5  by  10  mm.  The  uterine  wall  is  everywhere  thicker 
than  normal,  averaging  2.5  cm. 

In  this  case  it  is  readily  seen  that,  although  the  ajjpcarance  at  operation  was 
ver}'  suggestive,  the  tumor  on  section  bore  no  resemblance  whatever  to  sarcoma. 

Myomata  Macroscopic  ally  Presenting  the  Usual  Appearance,  but  Histologi- 
cally Containing  Areas  Suggestive  of  Sarcomatous  Degeneration. 

The  literature  contains  very  little  on  this  subject.  l)ut  we  are  certain  that  if 
a  systematic  examination  of  all  myomata  were  made  early,  sarcomatous  changes 
or  at  least  suspicious  pictures  would  occasionally  be  detected.  In  the  course  of 
our  investigation  at  least  twelve  tumors,  which  macroscopically  presented  little 
of  interest,  on  histologic  examination  yielded  pictures  more  or  less  suggestive 
of  sarcoma.  In  Case  3113,  although  the  myoma  as  a  whole  showed  little  that 
was  unusual,  nevertheless  at  several  points  the  muscle  nuclei  were  very  large 
and  contained  correspondingly  large  oval  or  almost  round  nuclei  (Fig.  162, 
p.  248). 

The  cell  alterations  in  Case  3295  are  very  instructive.  A  lobulated  sub- 
mucous myoma  had  been  removed,  and  on  histologic  study  at  the  junction  of 
two  lobulations  marked  cell  changes  were  noted.  At  this  point  some  of  the 
nuclei  were  normal  in  size;  others  were  four  to  five  times  the  usual  size,  and 
stained  deeph^  Some  nuclei  appeared  as  long  threads,  being  three  or  four 
times  the  normal  length,  and  others  cells  contained  three  or  four  luielei  Inmched 
together.  Such  a  field  is  strongly  suggestive  of  sarcoma.  A  rather  odd  co- 
incidence in  this  case  is  the  fact  that,  more  than  five  years  later,  the  uterus  was 
removed  on  account  of  an  adenocarcinoma  which  had  meanwhile  developed  just 
above  the  internal  os. 

Case  3461  is  also  a  good  example  of  changes  strongly  suggest iv(>  of  (>arly 
sarcoma  in  the  myoma.  The  tumor  was  composed  of  non-strijx'd  muscle-fibers 
which  were  markedly  separated  from  one  another,  tiie  entire  tissue  appearing  to 
be  edematous.  Many  of  the  muscle-fibers  were  normal,  but  numerous  unusual 
pictures  were  seen.  Here  and  \hrvv  were  spindle-shaped  cells  at  least  five  times 
the  usual  length  and  four  times  the  breadth.  These  contained  five  or  six  oval 
nuclei,  which  stained  iiioi'e  deeply  than  those  in  the  \ieinily.  In  (»lh('r  |)la('es 
four  or  five  nuclei  were  joined  end  to  end.  The  picture  instantly  suggests  sar- 
comatous transformation  of  muscle-fibers.  Such  cell  changes  were  found 
sparsely  scattered  throughout  the  tumor,  but  were  most  abundant  near  the 
peritoneal  surface. 


246  MVO.MATA    OF   THE    UTKRUS. 

In  San.  No.  577  wo  have  another  instructive  example  of  suspicious  cell  changes 
in  niyoinata.  The  myoma  was  situated  in  the  ])()sterior  uterine  Avail  and  was 
(Mlciuatous.  .Maci'oscopically,  there  was  not  the  faintest  suspicion  of  a  malignant 
change.  A  reference  to  the  patiiologic  report  shows  that  the  solid  portions  of 
the  tumor  presented  a  typical  myomatous  picture.  Occasionally,  however,  the 
muscle  nucleus  was  irr(»gular  in  outline,  stained  somewhat  deeply,  and  was  five 
or  six  times  the  usual  size.  At  other  points  the  muscle-fibers  had  luiclei  varying 
markedly  in  diameter.  On  careful  study  of  such  fields  the  following  were  noted: 
some  of  the  nuclei  were  small,  oval,  and  vesicular;  others  were  twice  the  normal 
dimensions,  while  (]uite  a  number  were  four  or  five  times  larger  than  normal  and 
had  irregular  outlines.  All  gradations  between  those  of  normal  size  and  the 
larger  ones  were  demonstrable.  Occasionally  large  masses  of  protoplasm  stain- 
ing deeply  with  eosin  and  containing  four  or  five  large  nuclei  bunched  in  their 
centers  were  noted.  Such  cells  are  depicted  in  Figs.  163  (p.  250)  and  165 
(p.  252).  At  other  points  long  fusiform  masses  of  protoplasm,  fully  twelve  times 
the  length  of  normal  muscle-fibers,  were  demonstrable^,  and  some  of  these  con- 
tained two  or  three  (enlarged  nuclei  bunched  in  their  centers.  One  of  these  large 
fusiform  cells  is  seen  in  Fig.  164  (p.  251),  extending  almost  the  entire  length  of 
the  field.  In  sections  from  the  softened  areas  of  the  myoma  all  trace  of  the 
myomatous  arrangement  had  entirely  disappeared.  The  tissue  was  rarefied, 
and  many  giant-cells  were  found.  Xowhere,  however,  were  nuclear  figures 
demonstrable,  nor  was  there  much  excess  of  chromatin.  In  this  case  the  entire 
histologic  picture  was  most  suggestive  of  sarcoma. 

Tlie  histologic  ])icture  seen  in  Fig.  166  (p.  253)  represents  a  large  giant-cell 
containing  many  small  nuclei  scattered  regularly  throughout  it.  This  was  the 
only  unusual  cell  found  in  the  myoma.  Fig.  167  (p.  253)  is  from  Case  5496,  in 
which  the  ])atient  suffered  from  ''recurrent  fibroids."  These  submucous  myo- 
mata  wei'e,  for  the  most  part,  necrotic:  in  many  places  no  cell  elements  remained, 
but  at  other  ])oints  were  fragments  of  nuclei  and  nmch  small-round-celled  and 
polymorphonuclear  infiltration.  In  the  figure  we  see  two  very  large  nmscle- 
fibers  with  correspondingly  large  and  irregular  miclei.  As  noted  in  the  history, 
this  patient  is  now  perfectly  well.  In  some  cases  in  which  the  myoma  is  under- 
going necrosis  much  inflanmiatory  reaction  has  taken  })lace.  We  occasionally 
encounter  rather  large  and  deejily  staining  nuclei,  as  seen  in  Fig.  168  (p.  256). 
They  suggest  slightly  a  malignant  change,  but  are  evidently  degeneratiA'c  phe- 
nomena. While  in  nearly  all  these  cases  evidences  of  sarcoma  were  ])rominent, 
in  none  of  them  were  we  justified  in  making  a  positive  diagnosis  of  malignancy. 
As  is  well  known,  early  carcinomata  may  often  be  recognized  by  commencing 
changes  in  the  epithelial  elements,  but  the  benign  alterations  in  coimective- 
tissue  growths  are  .so  manifold  and  fre([uently  resemble  to  so  remarkal)Ie  a  degree 
malignant  growths  that  one  is  often  at  a  loss  to  detei'tnine  whether  a  given  case 
is  l)enign  or  malignant,  and  must  await  the  subse(|ueiU  clinical  history  of  the 
case  or  be  ai)le  to  detect  metastases  befoi'c  savinu;  that   the  tumor  is  I'callv  sar- 


myosarco:ma  of  the  uterus.  247 

comatous.  On  the  other  hand,  the  growth  may  appear  benign  in  character,  and 
yet  the  chnical  history  may  show  that  it  is  mahgnant.  This  is  especially  true  of 
some  spindle-celled  sarcomata. 

Gyn.  No.  31 13.     Path.  No.  487, 

Interstitial  uterine  m  y  o  m  a  t  a  with  cell  changes 
somewhat  suggestive  of  sarcoma  (Fig.  162).  Very 
early  carcinoma  of  the  body  of  the  uterus  (Fig. 
18  4,    p.  2  95). 

A.  V.  G.,  white,  aged  fifty-two,  married.  Admitted  October  16;  dis- 
charged December  6,  1894.     The  abdominal  veins  were  greatly  distended. 

Operation,  October  24th.  Hysteromyomectomy.  There  was  excessive  vas- 
cularity of  the  uterus  and  of  the  tumors,  and  extensive  subperitoneal  myomatous 
development.  The  bladder  was  high  up  in  the  abdomen.  During  removal  of 
the  tumor  a  portion  of  the  bladder  wall  was  accidentally  removed.  The  ureters 
were  catheterized.  After  removal  of  the  uterus  the  bladder  was  sewed  up 
with  interrupted  sutures.     The  patient  made  an  uninterrupted  recover}-. 

Path.  No.  487.  The  specimen  consists  of  a  large  globular  tumor,  in  tlii; 
upper  part  of  which  the  uterus  is  situated.  Both  tubes  and  ovaries  are  intact. 
The  tumor  is  approximately  circular,  25  cm.  in  diameter.  On  its  lower  and 
anterior  surface  are  five  ill-defined  bosses,  the  largest  of  which  measures  8  x  5  x  3.5 
cm.  The  tumor  is  whitish  red  in  color,  smooth  and  glistening,  and  covered  with 
peritoneum.  The  under  cut  surface  presents  a  denuded  area,  25  x  15  cm.  On 
the  anterior  surface  of  the  tumor  is  a  piece  of  bladder  mucosa,  6x3  cm.  The 
tumor  on  pressure  is  firm  but  yielding,  and  gives  a  faint  sensation  of  fluctuation. 
On  section  it  is  whitish  in  color  and  presents  a  finely  striated  appearance.  Scat- 
tered throughout  the  tumor  are  sinuses,  the  largest  of  which  is  1.2  cm.  in  diam- 
eter. They  are  smooth-walled  and  communicate  with  one  another.  They 
contain  a  serous-like  fluid.  Some,  however,  are  filled  with  dark-red  blood. 
Most  of  these  sinuses  appear  to  be  lymphatic  in  origin. 

On  section,  it  is  found  that  the  entire  tumor  mass  springs  from  the  posterior 
uterine  wall.  It  is  int(U'stitial,  having  an  outer  covering  of  nniscle,  averaging 
2  mm.  in  thickness.  The  ])osterior  uterine  wall  is  also  filled  with  sinuses  smaller 
than  those  found  in  the  tumor. 

Histologic  Examination. — The  glands  of  the  cci'vix  in  i)lac("s  arc  dilated. 
The  uterine  mucosa  is  very  atrojihic.  'Hie  suifacc  cpitiicliuiu  is  intact.  The 
glands  ar(!  few  in  munbei-,  and  are  small  and  cii'cular  on  cross-si^ction.  The 
stroma  of  the  mucosa  shows  consi(lei';ii)le  lymphoid  infilt  I'ation.  and  non-st  i-ijicd 
muscle-fibers  are  seen  passing  uj)  into  the  stroma  of  the  mucosa  nearly  as  far  as 
the  uterine  cavity.  Spi-inging  fi-oin  the  mucosa  are  three  ])olypi,  one  situated 
near  the  internal  os  and  ha\"ing  a  broad  base;  the  second  is  1.5  cm.  from  the 
fundus  and  pedunculated;  a  third  is  situated  at  the  fimdus.  These  ]> :)l>'iti  are 
covered  with  cylindric  epithelium,  h;i\e  numerous  inlands  scattei'ed  throuLrhout 


248 


MViiMATA    OF    TIIK    rTERI'S. 


thcin,  some  of  which  arc  (Hinted,  others  empty.  Some  of  the  glands  coiitam 
polymorphoiUK'h'ar  leukocytes  and  desquamated  epithelium,  blood,  or  hyaline 
casts.     At  one  ]X)int  is  a  very  early  carcinoma  (Fig.  184,  p.  295). 

The  uterine  muscle  just  l)eneath  the  mucosa  appears  to  be  perfectly  normal. 
Ill  other  places  it  contains  numerous  small  empty  s])aces,  some  of  which  have  an 
endothelial  lining.  These  are  probably  lymph-spaces.  The  large  tumor  sit- 
uated in  the  ])osterior  wall  is  com{)osed  of  non-striped  muscle-fibers  which  show 
diffuse  hyaline  degeneration.  In  some  places  this  degeneration  is  so  marked 
that   the   muscle-bundles   appear  as   small  cells  in  hyaline  material.      There 

arc  many  recent  hemorrhages  which  arc  chiefly 
found  in  hyaline  areas.  In  some  places  the  tumor 
is  edematous.  In  no  place  can  polymorphonuclear 
leukocytes  l)e  detected.  The  blood-vessels  of  the 
tumor  are  moderate  in  number,  the  veins  pre- 
dominating. Scattered  everywhere  throughout  the 
tumor  are  large  and  small  empty  spaces,  some  with, 
others  without,  an  endothelial  lining.  As  the  blood 
in  the  arteries  and  veins  has  been  well  preserved 
in  Miiller's  fluid,  and  since  these  spaces  are  com- 
paratively   free    from    blood,    we    are    inclined    to 


9 

Fig.  162. — Large  Cells  Occur- 
ring IN  A  Simple  Intersti- 
tial Myo.ma.     (X  450diani.) 

Path.  No.  487.  a  represents     bclievc    that    they    are    lymph-channels.      Passing 

the  average  size  of  the  nuclei  of  ,  . 

the  muscle-fibers.   At  b  are  two     across  souic  of  the  suiallcr  spaccs  are  delicate  capil- 

nuclei,  approximately  spheric  and 
much  enlarged.  Their  chromatin 
is,  however,  only  slightly  in- 
creased. Above  and  below  the 
center  many  of  the  nuclei  tend 
to  overlap  one  another  and  to 
arrange  themselves  in  rows,  c 
indicates  some  small-round-celled 
infiltration.  After  detecting  the 
large  nuclei  (b)  further  sections 
should  be  examined  to  see  if  more 
definite  signs  of  sarcoma  are  i)res- 
ent.  From  these  nuclei  alone  we 
would  not  be  warranted  in  saying 
that  the  growth  was  malignant. 


laries,  just  large  enough  to  admit  the  passage  of 
one  red  blood-corpuscle  at  a  time.  In  one  of  the 
large  arteries  a  hyalin(>  thrombus  is  seen.  The  tubes 
and  ovaries  are  normal. 

The  chief  interest  in  the  case  centers  in  the  pres- 
ence of  some  very  large  cells  containing  equally  large 
oval  or  almost  round  vesicular  nuclei  (Fig.  162). 
These  suggest  to  a  slight  degree  commencing  .sar- 
comatous transformation,  but  are  by  no  means 
conclusive. 

After  the  opei'atioii   the  patient  did  j)erfectly  well,  but  she  could  not  retain 
ler  water  long  without  some  pain. 


Gyn.  No.  3295.     Path.  Nos.  582  and  3948. 

S  u  b  111  u  c  o  u  s  m  y  o  m  a  s  h  o  w  i  n  g  cell  changes  very  sug- 
gestive of  s  a  r  c  o  m  a  .  Y  i  v  (>  y  e  a  r  s  1  a  t  0  r  c  o  m  p  1  e  t  e  h  3'  s  - 
t  c  r  e  c  t  o  m  y  f  o  r  a  n  ad  e  n  o  c  a  r  c  i  n  o  m  a  apparently  orig- 
inating   in    the    body    of    the  uterus. 

R.  B.,  white,  aged  forty-five,  married.  Admitted  January  24;  discharged 
February  23,  1895.  She  has  l)een  married  twenty-three  years,  but  has  had  no 
children  and  no  miscarriages.     Eighteen  years  ago,  when  suffering  from  uterine 


MYOSARCOMA    OF    THE    UTERUS.  249 

hemorrhages,  the  patient  was  told  that  she  had  a  tuinor.  and  eight  years  ago 
noticed  what  seemed  to  be  a  tumor  })rotruding  fi'om  tlic  vulva.  She  was  re- 
Heved  somewhat  by  wearing  a  pessary.  For  the  jxist  two  years,  at  intervals 
of  a  few  days  to  two  weeks,  she  has  had  a  hemorrhage  from  the  vagina,  usually 
appearing  as  large  dark  clots. 

Operation,  January  30,  1895.  Vaginal  myomectomy.  The  ])atient  made  a 
satisfactory  recovery. 

Path.  No.  582.  The  specimen  consists  of  an  irregular  and  globular  mass, 
10  cm.  in  diameter.  This  is  coarsely  lobulated,  pinkish  in  color,  and  covered 
with  numerous  adhesions.  At  one  extremity  is  a  raw  surface,  6.5  x  5  cm.  This 
corresponds  to  the  pedicle.  The  tumor  is  firm  and  non-yielding;  on  section  it 
is  whitish  pink  in  color,  and  consists  of  concentrically  arranged  striie. 

Histologic  Examination.— The  outer  surface  of  the  tumor  is  covered  with 
several  layers  of  cells,  from  nearly  all  of  which  the  nuclei  have  disajiiK-ared. 
There  is  no  evidence  of  nuicosa.  The  tumor  is  composed  of  non-striped  muscle- 
fibers  cut  both  longitudinally  and  transversely,  and  the  tissue  shows  much 
hyaline  degeneration.  These  degenerated  areas  are  scattered  irregularly  through- 
out the  muscle,  and  in  such  places  a  few  isolated  muscle-fibers  are  still  visible. 
The  tissue  just  beneath  the  outer  surface  has  a  rich  blood-supply.  At  one  point, 
where  one  lobulation  joins  another,  the  nmscle-cells  are  markedly  altered. 
Some  of  their  nuclei  are  normal  in  size,  others  are  four  times  as  large  as  usual  and 
stain  deeply.  Some  of  the  nuclei  appear  as  long  threads,  three  times  the  normal 
length,  and  other  cells  contain  three  or  four  nuclei  bunched  together.  The 
picture  is  a  very  unusual  one  and,  were  only  such  a  field  in  question,  one  might 
be  warranted  in  making  a  diagnosis  of  sarcoma.  But  the  gross  appearance  of 
this  area  is  identical  with  that  of  an  ordinary  myoma,  and,  as  seen  from  the 
description,  the  surrounding  muscle-fibers  are  of  the  ty])e  so  constant  in  myoma. 
It  is  possible  that  there  is  a  commencing  sarcomatous  degeneration,  but  if  so, 
it  is  in  an  exceedingly  early  stage. 

Path.  No.  3948.  The  specimen  consists  of  the  entii'e  uterus.  The  upper 
part  of  the  cervix  and  lower  part  of  the  bod\'  are  in\()l\'ed  in  a  cancei-ous  grow  th 
which,  on  histologic  examination,  ))roved  to  be  an  adenoeaicinoiiia.  Theiv  is 
also  a  small  interstitial  myoma. 

In  October,  1902,  the  patient  retui'iied  with  ;iii  inoperable  ivcuireiice  in  the 
vagina. 

This  case  is  particularly  interesting  on  account  of  the  clianges  th;il  took  place 
in  the  subnmcous  myoma,  and  IVom  the  fad  that  li\-e  years  later  carciiioniM  de- 
velojK'd.  The  coincidence  of  these  two  is  certainly  an  accideiilal  occuri'eiice, 
the  one  ap])earing  indeixMideiil  ly  ol'  the  other. 

San.  No.  577.     Path.  No.  2402. 

An  edematous  s  u  b  |)  e  i' i  t  o  11  e  a  1  111  y  o  m  ;i  ])resenting 
histologic  c  h  a  n  g  e  s  s  t  r  o  n  g  1  y  s  u  g  g  est  i  \-  e  o  I'  s  a  r  c  o  m  a 
( F  i  g  s  .   1 6  3 ,    16  4,165). 


250 


MYO.MATA    OK   THK    UTERUS. 


11  K.,  white,  afi'cd  fifty,  siniilc.  Admitted  March  15;  discharged  April  19, 
ISOS.     Coiiiplaint,  a  constant  flow  for  the  last  three  months. 

Operation,  March  17,  1898.  Hysterectomy.  The  ])atient  made  a  satisfac- 
tory recover}. 

Path.  No.  2402.  The  specimen  consists  of  an  enlarged  uterus  which  has 
heen  coin-erted  into  a  glohuhir  tumor,  12  x  11  x  11  cm.  Its  surface  is  free  from 
adhesions.  The  increase  in  size  of  the  uterus  is  due  to  the  presence  of  a  tumor 
that  occupies  its  posterior  wall.  The  anterior  wall  is  of  the  normal  thickness. 
The  uterine  cavity  is  5.5  cm.  long  and  3  cm.  broad  at  the  fumhis.  The  mucous 
membrane  has  an  un(hilating  surface.     The  tumor  occupying  the  posterior  wall 

is  approximately    10  cm.   in  dia- 

c       Tj  meter.     At  some  points  it  presents 

m  a  typical   myomatous  appearance, 

(^  -d'  ^'^^^'  '^^  niany  places  between 
nuiscle-bundles  are  less  dense  areas, 
presenting  a  homogeneous  surface 
and  entirely  devoid  of  a  myomat- 
ous arrangement.  These  closely 
resemble  edematous  areas.  Here 
and  there  are  small  irregular  empty 
sj^aces,  so  often  seen  where  a 
myoma  is  breaking  down.  The 
most  j)rominent  portion  of  the 
specimen  contains  an  irregular 
hemorrhagic  area,  4  cm.  in  dia- 
meter. This  has  in  part  broken 
down,  and  clinging  to  the  walls  of 
the  cavity  are  small  blood-vessels. 
There  is  a  second  area  of  hemor- 
rhage, but  here  no  dissolution  has 
taken  place.  Tn  the  neighborhood 
of  the  uterus  the  tumor  has  a 
covering  of  muscle  varying  from  1  to  8  mm.  in  thickness.  But  at  the  point 
most  distant  from  the  organ  the  growth  is  pi'actically  devoid  of  nmscular 
covering,  and  the  fibers  of  the  tumor  are  clearly  visible.  From  the  foregoing 
description  it  will  be  seen  that  the  tumor  appears  to  be  an  ortUnary  myoma 
in  which  some  degeneration  has  taken  ])lace.  The  gross  appearance  in  no  way 
suggests  a  malignant  })rocess. 

Histologic  Examination. — The  uterine  cavity  appears  to  be  normal.  Sections 
from  the  solid  portion  of  the  tumor  in  many  places  3'ield  typical  myomatous 
tissue.  Occasionally,  however,  we  find  a  nucleus  five  or  six  times  the  usual 
.size,  irregular  in  shape,  and  staining  fairly  deeply.  This  tis.sue  also  contains 
small  round  cells,  freely  interspersed  between  nuiscle-bundles,  but  apparentiv 


lt)3. — (JiAXT-CKLLS  i\  AN'  Edematois  Mvoma.     (X  420 

diain.) 
Path.  No.  2402.  a  represents  the  average  size  of  a 
muscle  nucleus;  b  is  a  shade  larger  and  stains  a  little  more 
intensely;  c  shows  partial  subdivision;  d,  d',  d",  d'",  and 
d""  depict  various  stages  in  the  development  of  giant-cells. 
Note  that  all  of  the  nuclei  of  the  giant-cells,  although  in- 
creased in  size,  show  little  or  no  increase  in  chromatin.  The 
tissue  is  sparsely  infiltrated  with  small  round  cells,  as 
indicated  by  e.  This  field,  while  slightly  suggestive  of  sar- 
coma, is  almost  too  cjuiet  to  make  one  very  suspicioas. 


MYOSARCOMA    OF   THE    UTERUS. 


251 


no  polyinorphoiuK'lear  leukocytes.  At  other  points  the  niuscle-tibers  have 
nuclei  varying  markedly  in  size.  Careful  scrutiny  of  such  fields  shows  that  some 
of  the  nuclei  are  small,  oval,  and 
vesicular;  that  others  are  twice  the 
natural  size,  while  a  number  are  four 
or  five  times  the  normal  size,  are 
irregular  in  shape,  but  do  not  stain 
deeply.  All  gradations  between  the 
normal  nuclei  and  the  large  ones  are 
demonstrable.  Occasionally  we  note 
a  large  mass  of  protoplasm  staining 
deeply  with  eosin  and  containing  four 
or  five  of  these  large  nuclei  bunched 
in  its  center  (Figs.  163  and  165).  At 
other  points  are  long,  fusiform  masses 
of  protoplasm,  sharply  defined  from 
the  fact  that  they  take  the  eosin 
stain  so  deeply.  These  are  sometimes 
twelve  times  as  long  as  the  normal 
muscle-fibers  (Fig.  164).  The  giant 
fibers  occasionally  contain  two  or 
three  somewhat  enlarged  nuclei, 
bunched  in  their  centers.  There  is 
one  cell  of  this  character  which  con- 
tains three  nuclei — one  of  the  normal 
size,  the  second  about  three  times, 
and  a  third  about  ten  times,  the  usual 
diameter.  This  largest  nucleus  has 
a  distinctly  hyaline  droplet  in  its 
center.  Sections  from  the  softened 
areas  are  still  more  startling.  The 
typical  arrangement  of  the  myoma 
has  entirely  disappeared.  The  cells 
vary  greatly  in  size,  and  there  are 
many  large  plaques  of  protoplasm, 
varying  in  diameter,  staining  deeply, 
and  containing  anywhere  from  one 
to  four  or  five  nuclei.  The  more 
rai'efied  the  tissue,  the  moi'c  abund- 
ant these  giant-cells.  In  I  he  areas 
in  which  the  hemorrhage  has  taken  place  we  (iik 
\()  nuclear  figures  can  be  detected  in  the  tuinoi'. 

I'^roni  the  foregoing  description  one  is  instantly  reinin(le(l  of  sai'coni; 


Fin.  164. — Su.spicious  Ckll  Changes  ix  ax  Edematous 
AND  Partly  Subperitoneal  Myoma.     (X  350diam.) 

Path.  No.  2402.  a  shows  the  average  size  of  the 
muscle  nuclei  on  cross-section.  At  h  we  have  a  spindle- 
shaped  cell  cut  longitudinally.  c  represents  one  of 
several  large  nuclei,  c'  is  also  a  large  nucleus,  but  its 
chromatin  is  diminished  instead  of  being  augmenteil. 
The  nuclei  tend  to  form  dumps  at  d.  .\t  e  the  nuclei  are 
much  larger,  and  the  same  tendency  toward  clumping  is 
noted.  Here  the  largest  nucleus  contains  the  hyaline 
droplet  f.  g  is  the  pnjtoiila-sm  of  a  cell  that  can  be  traceti 
nearly  the  entire  length  of  the  held.  Near  its  lower  por- 
tion it  contains  the  clump  of  nuclei  (h).  M  its  middle 
is  a  group  of  nuclei  ihM,  and  in  the  upper  portion  a 
small  nucleus  (h").  There  is  some  small-round-cclleii 
infiltratiim,  as  indicated  by  i. 

The  presence  of  the  gigantic  cell  g,  with  its  clumps 
of  nuclei,  liigctlicr  with  the  large  nuclei  scattered  through- 
out the  field,  make  one  mindful  of  sarcoma.  The  knowl- 
edge, however,  that  we  are  dealing  with  an  edematous 
myoma  should  deter  us  from  making  a  positive  diagnosis 
■  if  malignancy.  See  Figs.  1():{  and  Iti.")  for  sections  from 
I  lie  same  m>oma. 

nuniliers  dl'  I  hese  gi;int-eells. 
\t  no 


252  MVOMATA    OF    THE    UTERUS. 

point,  however,  do  we  find  typical  sarcomatous  tissue,  nor  do  we  find  a  very 
marked  tendency  to  an  increase  in  amount  of  nuclear  chromatin.  Furthermore, 
it  will  be  noticed  that  the  most  pronounced  changes  are  found  in  th(^  rarehed  areas. 
At  no  point  in  the  gross  specimen  were  we  able  to  detect  a  solid  and  circumscribed 
homogeneous  area,  so  characteristic  of  sarcoma.  It  is  inipossil)le  to  render  a 
positive  diagnosis,  but  the  probability  is  that  no  sarcoma  is  ])resent.  From  a 
clinical  standpoint,  however,  should  we  find  tissue  of  such  a  character  in  a 
myoma,  it  is  incumbent  on  the  pathologist  to  advise  immediate  and  complete 
removal  of  the  uterus. 

November  27,  1902,  four  years  and  a  half  after  the  oi)eration,  the  patient 
writes  that  she  is  in  good  health. 

Gyn.  No.  5635.     Path.  No.  1973. 
October,  1897.     The  specimen  consists  of  a  small  myoma  from  the  right 
horn.     This  measures  5x4x2  cm.     On  histologic  examination  it  presents  the 
typical  myomatous  picture.     It  contains  one  suspicious  area,  as  depicted  in 
Fig.  166. 


i£&'W  >*; £!_. 

A 

Fig.  165. — Giant-cells  from  an  Edem.vtous  Myoma.     (X  .320diaiii.) 

A.  Path.  No.  2402.  The  nuclei  are,  on  the  whole,  more  oval  than  spindle-shaped,  but  are  of  the  usual  size, 
a  is  a  very  large  mass  of  protoplasm  containing  four  nuclei  of  various  sizes. 

B.  a  is  a  very  large  irregular  plaque  of  protoplasm  surrounded  by  nuclei  of  muscle-fibers.  It  contains  five 
goodly  sized  nuclei  and  several  smaller  ones  (b).     Their  chromatin  is  slightly  increased;  c  is  a  small  round  cell. 

These  two  giant-cells  are  somewhat  suspicious  of  sarcomatous  changes,  and  should  stimulate  further  ex- 
amination of  the  tumor. 

Gyn.  Nos.  5496  and  5907.  Path.  Nos.  1899  and  2222. 

''Recurrent  fi  1)  r  o  i  d  '  '  ^^■  i  t  h  histologic  a  })  p  e  a  r  a  n  c  e 
s  t  r  o  n  g  1  5'    suggestive  of  sarcoma   (Fig.   167). 

M.  D.,  white,  married,  aged  thirty-eight.  Admitted  September  3:  discharged 
September  30,  1897.  The  patient  has  l)een  married  fourteen  years;  she  has  had 
no  children,  but  two  miscarriages.  The  menses  began  at  thirteen  and  were 
regular  until  six  months  ago,  when  the  flow  became  scant.  Three  months  ago 
she  had  a  hemorrhage,  and  since  then  has  had  frequent  bleetling.  For  three 
years  there  has  been  a  thick,  offensive  leukorrheal  discharge,  and  for  the  past 
three  months  constant  ])ain  in  the  lower  abdomen.  During  this  time  she  has 
become  very  weak. 

Operation,  September  4,  1897.  Vaginal  myomectomy.  A  large,  cauliflowtT- 
like  myoma  projected  into  the  vagina.     It  was  about  10  cm.  in  diameter,  very 


MYOSARCOMA    OF   THK    ITKRUS. 


25." 


friable,  and  bled  profu«ely.  The  uterine  cavity  was  packed.  Her  temperature 
on  admission  was  101.5°  F.  After  operation  it  rose  to  103.6°,  and  on  the  third 
day  gradually  fell  to  normal.  The  i)atient  rapidly  gained  fiesh  and  strength  and 
was  discharged  feeling  well. 

Path.  No.  1899.  The  specimen  consists  of  numerous  fragments  of  tissue 
from  the  uterine  cavity. 

Histologic  Examination. — The  tissue  has  to  a  great  extent  undergone  de- 
generation, but  at  some  points,  especially  around  the  blood-vessels,  the  cells  are 
still  preserved.     They  are  spindle-shaped,  closely  packed  together,  and  form 


Fig.  166. — A  Large  Nucleus  in  a  Myoma.  (X  320 
diam.) 
Path.  No.  1973.  a  represents  the  average  size  of 
the  nuclei.  .\t  b  is  a  nucleus  somewhat  enlarged,  c 
is  a  much  elongated,  oval-shaped  giant-cell  contain- 
ing more  than  twenty  nuclei,  which  stain  more  deeply 
than  those  in  the  surrounding  tissues.  Apart  from  the 
one  giant-cell,  nothing  unusual  was  noted  in  the 
myoma,  and  this  large  cell  alone  would  scarcely  sug- 
gest a  malignant  change. 

whorl.-;  or  run  in  various  directions. 
The  picture  instantly  reminds  one  of 
myomatous  tissue.  At  some  distance 
from  the  vessels  the  tissue  is  found  to 


i. 


& a 

'  "r-e 


W 


-aWSK 


(# 


jr.JS. 


Fig.  167. — Suspicious  Cell  Changes  in  a  Sloughing 
Submucous  Myoma.    (X  315  diam.) 

Path.  No.  1899.  The  nuclei  are  few  and  far  be- 
tween, much  of  the  tissue  having  undergone  hyaline 
change,  a  represents  the  average  .size  of  the  nuclei 
of  the  muscle-fibers.  At  b  are  a  few  red  corpuscles;  at 
c  a  polymorphonuclear  leukocyte,  d  is  a  large  plaque 
of  protoplasm  containing  two  enlarged  nuclei,  over- 
lapping one  another,  e  is  also  a  mass  of  protoplasm 
containing  two  very  large  and  deeply  staining  nuclei. 
Below  this  cell  is  another  clump  of  protoplasm  devoid 
of  nuclei. 

The  two  large  cells,  d  and  e,  make  one  very  suspi- 
cious of  malignancy,  and  further  tissues  should  be 
examined.  Such  pictures  are  occasionally  found  in 
edematous  myomata.  From  this  field  alone  one 
would  not  be  justified  in  saying  that  the  growth  is 
malignant. 


show  marked  hyaline  degeneration. 
Other  ])()rtions  of  the  tumor  have  undergone  complete  necro.^i.^;,  not  a  nucleus 
being  visible.  Here  and  there  a  few  large,  suspicious-looking  muscle-libers  are 
seen  (Fig.  167).  Where  the  necrosis  has  taken  place,  the  l)l()(>(l-vess('ls  are 
exceedingly  numerous  and  arc  much  dilated.     Some  of  them  coniaiii  tliroiiibi. 

Gyn.  No.  5907.  The  ])atient  was  readmit  led  on  Mairh  2.  JSilS.  and  di.<- 
charg(>d  on  March  30,  189S. 

In  November,  1S97,  about  two  months  after  her  o])ei'alion  at  the  hospital,  a 
sloughing  sul)iiiu('ous  myoma  was  reiiioxcd  by  her  family  |)hysician.  For  two 
months  she  was  relie\-ed,  but   then  eoiiinieiiced  to  lose  Hesh  and  had  chills  and 


254  MVo.MATA    OF   THE    UTERUS. 

fever.  Fur  tlie  past  two  week.s  she  has  had  pain  and  tenderness  in  the  lower  left 
abdomen. 

Operation,  March  4,  1898.  A'aginal  myomectomy.  A  pedunculated  slough- 
ing submucous  myoma.  9  cm.  in  diameter,  was  removed  from  the  vagina. 
There  was  a  consiilerahle  degree  of  inversion  of  the  uterus.  Her  temperature 
after  the  ojx'ration  reached  I()o.4°,  but  after  the  fiftli  day  gradually  dropjK'd 
to  normal,  and  she  was  discharged,  feeling  well. 

l^ith.  No.  2222.  The  specimen  consists  of  many  pieces  of  tissue,  the  largest 
5  cm.  ill  diameter.  It  is  very  firm,  and  on  section  is  yellowish  white  in  color, 
and  apparently  consists  of  bands  of  fibrous  tissue  running  in  all  directions. 
Other  ]iortions  show  marked  dilatation  of  the  blood-vessels.  Many  of  these  are 
surrounded  by  a  zone  of  hemorrhage,  and  some  portions  of  the  tumor  are  hemor- 
rhagic throughout.  Along  the  edges  of  some  of  the  })ieces  the  tissue  is  very 
friable,  looks  necrotic,  and  has  an  exceedingly  offensive  odor. 

Plistologic  Examination. — The  solid  portion  is  composed  of  bunches  of  cells 
cut  longitudinally  and  transversely.  The  nuclei  are  oval,  elongate-oval,  or  in 
some  places  spindle-shaped.  They  are  fairly  uniform  in  size,  and  take  the  stain 
evenly.  Occasionally  a  nucleus  is  two  or  three  times  as  large  as  an  adjoining 
one,  and  now  and  th(>n  one  sees  a  large  mass  of  chromatin,  somewhat  granular 
and  ap])arently  divided  up  into  several  smaller  nuclei.  The  tissue  bears  much 
reseml)lance  to  a  myoma,  but  the  connective  tissue  is  conspicuous  by  its  absence. 
The  blood-vessels  are  fairly  abundant.  In  other  sections  in  which  the  tissue  was 
softer  the  same  spindle-shaped  cells  are  present,  but  are  to  a  great  extent  sepa- 
rated from  one  another  by  blood-corpuscles.  Scattered  throughout  the  hyaline 
tissue  are  ]X)lymori)honuclear  leukocytes.  The  surface  of  the  offensive  ])()rtions 
is  composed  almost  entirely  of  leukocytes.  From  the  macroscopic  examination 
one  would  naturally  make  a  diagnosis  of  sui)purating  myoma,  but  the  presence 
of  the  few  large  cells  noted  histologically,  and  the  fact  that  there  is  little  connec- 
tive tissue,  make  the  presence  of  sarcoma  quite  ])robable.  From  a  histologic 
standpoint  it  is  not  advisable  to  make  a  positive  diagnosis.  One  must  be  guided 
entirely  by  the  clinical  history. 

November  14,  1902,  the  patient  writes  that  she  has  been  ])erfectly  well  since 
the  last  operation,  and  that  her  weight,  which  was  formerly  90  pounds,  is  now 
143  pounds.     It  is  over  four  and  a  half  years  since  the  last  operation. 

Gyn.  No.  3461.     Path.  No.  682. 

S  u  b  m  u  c  o  u  s  ,  interstitial,  a  11  d  s  u  b  p  e  r  i  t  o  n  e  a  1  m  y  o- 
m  a  t  a  .  S  11  b  p  e  r  i  t  o  n  e  a  1  m  y  o  111  a  s  h  o  w  i  n  g  m  a  r  k  e  d  v  a  s- 
c  u  1  a  r  i  t  y  and  a  p  j)  a  r  e  11  t  1  \'  u  11  d  e  r  g  o  i  n  g  s  a  r  c  o  111  a  t  o  u  s 
transformation. 

M.  C,  white,  aged  forty-nine,  married.  Admitted  April  2o;  discharged 
May  18,  1895.  The  patient  has  had  no  children  and  no  miscarriages.  One  year 
ago  she  had  a  severe  attack  of  yimu  in  the  lower  abdomen,  and  now  has  constant 


MYOSARCOMA    OF    THE    TTHRI'S.  2oo 

pain,  worse  on  the  left  side,  and  extending  down  to  the  limbs  and  l)aek.  The 
abdomen  is  somewhat  tender;  micturition  is  frequent  and  painful.  Defecation 
is  painful. 

Operation,  May  24,  1895.  H^^steromyomectomy  and  herniotomy  for  incar- 
cerated femoral  hernia.     The  patient  made  a  satisfactoiy  recovery. 

Path.  No.  682.  The  specimen  comprises  the  uterus  and  a  large  myoma 
springing  from  its  left  side.  The  appendages  are  also  present.  The  uterus  is 
somewhat  irregular  in  outline,  and  measures  9x6x6  cm.  It  is  smooth  and 
glistening,  but  springing  from  its  anterior  wall  is  a  pedunculated  nodule,  1  cm. 
in  diameter,  and  a  sessile  nodule,  2  cm.  in  diameter.  A  small  nodule  projects 
from  the  fundus.  All  these  are  firm  and  non-yielding.  Situated  in  the  fundus 
is  an  interstitial  nodule,  4  cm.  in  diameter.  This  is  yellowish- white  in  color,  antl 
presents  a  striated  appearance;  it  is  firm  and  non-yielding.  The  uterine  cavity 
is  4  cm.  in  length.  Its  mucosa  is  grayish-white  in  color  and  presents  a  slightly 
granular  appearance.  That  covering  the  anterior  wall  contains  small  cysts. 
Springing  from  the  middle  of  the  left  side  of  the  uterus  is  a  globular  tumor, 
12  X  11  X  10  cm.  This  is  connected  with  the  uterus  by  a  round  pedicle,  4.5  cm. 
in  diameter,  4.5  cm.  in  length.  It  is  bluish-white  in  color,  and  contains  many 
superficial  vessels  which  spring  from  the  uterus  and  ramify  over  the  tumor. 
Over  its  upper  portion  the  tumor  is  bright  red,  but  in  the  dependent  i)ortions 
bluish  red.  It  is  everywhere  covered  with  peritoneum,  is  soft  and  somewhat 
yielding,  and  where  pressure  is  exerted,  the  tissue  becomes  blanched,  but  is  very 
vascular.     The  appendages  are  normal. 

Histologic  Examination. — The  uterine  mucosa  is,  on  the  whole,  normal. 
Projecting  into  the  uterine  cavity  is  a  polyp  consisting  of  nuicosa.  The  sub- 
nmcous  myoma  is  composed  of  non-striped  nmscle-fibers  cut  longitudinally  and 
transversely.  They  are  closely  packed  together,  and  stain  nmch  more  deeply 
than  do  those  of  the  uterine  muscle.  The  myoma  is  intimately  connected  with 
the  uterine  niuscl(\  Sections  through  the  i)edicle  of  the  tumor  springing  from 
the  left  side  show  that  it  is  quite  vascular.  The  tumor  is  comix)sed  of  non- 
striped  muscle-fibers  which  are  markedly  se])arated  from  one  another,  the  ciitiiv 
tissue  appearing  to  be  edematous.  Many  of  the  muscle-fibers  are  normal,  but 
numerous  unusual  forms  are  seen.  Here  and  there  ar(>  sjiindle-shaped  cells 
at  least  five  times  the  usual  length  and  four  times  th(>  normal  breadth.  These 
contain  five  or  six  oval  nuclei,  which  stain  more  deeply  than  those  neai"  them. 
In  other  places  four  or  five  nuclei  are  joini'd  end  to  end.  One  is  immediately 
rennnded  of  sarcomatous  tran.sformation  of  the  inuscle-libers.  Such  cells  are 
found  sparsely  scattered  throughout  the  tumor,  but  they  are  most  abun<l;uit 
near  the  ])eritoneal  surface.  Toward  the  center  of  the  tumor  are  homogeneous 
areas  which  stain  ])ink  with  eosin,  and  sprinkled  throughout  these  ai'eas  are  a 
few  nmscle-fibers.  It  looks  as  if  the  tissue  weiv  becoming  li(iuefied.  The  outer 
portions  of  the  tumor  are  exceedingly  \asculai-,  i)olh  the  arteries  and  veins 
being  very  abundant,  and  it    is  in   the  \icinily  of  these  blood-vesst>ls  that    the 


256  .MYOMATA    OF    THK    UTERUS. 

atyj)ical  cells  ai'c  most  niinierous.  The  vessels  arc  so  numerous  that  the  tumor 
might  be  justly  called  an  angioma. 

We  must  coiisidei'  the  tumor  ))iimarily  as  a  myoma  which  has  such  a  rich 
l)lo()(l-supi)ly  that  it  might  he  called  an  angiomyoma.  Secondly,  from  the 
aty))ical  cells  we  nuist  strongly  susjx'ct  .sarcoma  or,  to  say  the  least,  an  exceed- 
ingly rajMcUy  growing  myoma. 

November  13,  1902,  the  patient  writes  that  she  is  not  feeling  very  well,  but 
her  description  of  her  condition  is  not  definite.  The  length  of  time  since  opera- 
tion—seven and  a  half  years— demonstrates  clearly  that  even  if,  by  any  chance, 
the  piocess  was  malignant,  the  sarcoma  had  been  completely  removed. 


^ 

••« 

»• 

-^ii 

Fic.  168. — Ckll  Chancks  in  a  Myoma  Undergoi.m;  Partial  Coagulation  Necrosis.  (X  130  diam.) 
Path.  No.  2372.  The  section  is  from  the  neighborhood  of  an  area  which  has  undergone  coagulation  necrosis. 
The  area  indicated  by  (a)  consists  of  hyaline  myomatous  tissue.  Many  of  the  nuclei,  as  shown  at  b,  have  lost  their 
outlines  and  consist  merely  of  fine  granular  cliromatin.  .A.t  c  is  a  nucleus  slightly  enlarged  and  staining  deeply, 
and  at  several  points  we  have  small  aggrogatioiis  of  nuclei  tending  to  form  giant-cells.  This  is  well  seen  at  d. 
Scattered  throughout  the  field  are  many  small  round  cells  and  a  moderate  number  of  polymorphonuclear  levikocytes. 
Such  an  infiltration  is  very  common  in  the  tissvie  surrounding  an  area  of  coagulation  necrosis.  The  giant-cells 
impress  one  as  being  the  result  of  a  breaking  up  of  the  cells,  with  the  subsetiuent  coalescence  of  the  surviving  nuclei. 
.\lthough  at  first  sight  the  cell  changes  suggest  to  a  slight  degree  sarcoma,  a  careful  an.alysis  of  the  cells  clearly 
shows  that  there  is  no  evidence  of  m.alignancy. 

San.  No.  581.     Path.  No.  2372. 

Degenerative  change  in  a  myoma  that  might  be 
mist  a  k  e  n   f  o  r  s  a  r  c  o  m  a   (Fig.  168). 

M.  Operation  March  22,  189S.  Myomectomy.  The  specimen  consists  of 
five  myomata.  The  largest  is  lobulated,  and  measures  9x8x7  cm.  The 
others  are  much  smaller.  The  large  nodule  is  very  friable,  tears  easily,  and 
shows  marked  degeneration. 

Hi.stologic   Examination. — Sections  from  the  undegenerated  portion  of  the 


MYOSARCOMA    OF    THE    UTERUS,  257 

nodule  present  the  usual  myomatous  picture.  The  greater  part  of  the  tumor 
consists  of  hyaline  material,  but  separating  this  from  the  outer  and  still  well- 
preserved  tissue  is  a  zone  of  coagulation  necrosis,  for  the  most  part  consisting  of 
granular  material  that  stains  with  eosin,  and  of  nuclear  detritus.  Scattered 
throughout  the  outer  portion  of  the  necrotic  zone  are  cells  containing  deeply 
staining  nuclei  of  various  sizes  (Fig.  168).  Many  of  the  cells  contam  several 
such  nuclei.  One  gathers  the  impression  that  such  pictures  are  due  to  the  fact 
that  adjoining  cells  have  fused  with  one  another. 

Gyn.  Nos.  6407  and  12 139.     Path.  No.  8750. 

Large  m  u  1 1  i  n  o  d  u  1  a  r  m  y  o  m  a  t  o  u  s  u  t  c  r  u  s  ^^■  i  t  h  g  c  n  - 
e  r  a  1  p  civic  a  d  h  e  s  i  o  n  s ;  marked  hyaline  degeneration 
of  the  m  y  o  m  a  ,  jm-  e  s  e  n  t  i  n  g  a  picture  at  fi  r  s  t  suggestive 
of  sarcoma,  but  on  further  examination  1)  e  a  r  i  n  g  no 
d  e  fi  n  i  t  e  resemblance  to  such  a  condition. 

M.  R.,  colored,  aged  forty-two,  single.  Admitted  May  20;  discharged 
June  17,  1905.  The  patient  was  in  the  hospital  (Gyn.  No.  6407)  in  October, 
1898,  with  a  right  pyosalpinx  and  an  encysted  peritonitis,  which  was  opened 
through  the  vaginal  vault  and  drained.  One  month  after  leaving  the  hospital 
she  had  an  attack  of  pain  which  commenced  in  the  lower  abdomen  and  extended 
down  the  thighs.  Since  then  she  has  had  four  more  d(>finite  attacks  of  severe 
pain. 

Operation,  May  27,  1905.  Hysteromyomectomy  and  appendectomy.  On 
opening  the  abdomen  the  omentum  was  found  everywhere  adherent  to  the  pelvic 
organs.  It  was  tucked  down  behind  the  uterus  and  adnexa  to  the  bottom  of 
the  cul-de-sac.  After  releasing  the  omentum  Ave  found  that  we  were  dealing 
with  a  large  multinodular  myomatous  uterus.  On  the  right  side  there  was  a 
chronic  salpingitis.  The  tube  and  ovary  were  j)lastered  down  to  the  back  of 
the  broad  ligament.  On  the  left  side  there  was  an  adherent  ovarian  cyst.  6  cm. 
in  diameter.  A  supravaginal  amputation  was  pcrfornied,  and  the  i)atieiit  iiiaile 
a  very  satisfactory  recovery. 

Path.  No.  8750.  The  specimen  consists  of  a  lobulatcd  myomatous  uterus 
to  which  the  omentum  is  densely  adherent.  The  uterus  with  its  nodul(>  is 
10  cm.  in  length,  12  cm.  in  breadth,  and  S  cm.  in  its  antt-roiiosterior  diameter. 
Projecting  from  the  surface  are  pedunculated  and  sessile  myomata,  the  largest 
reaching  5  cm.  in  diameter.  Covering  the  surface,  and  intimately  blended  witii 
the  myomata,  is  the  omentum.  Scattered  throughout  tiie  uteiine  walls  are 
smaller  myomata,  some  of  them  subnuicous.  Attached  to  one  side  is  a  cystic 
mass,  7  cm.  in  diameter,  also  covered  by  adhesions.  It  appears  to  be  composed 
of  the  tube  and  ovary,  but  the  exact  relations  are  dilficult  to  establish. 

Histologic  Exaininalioii.  Sections  IVoni  the  myomata  show  hyaline  tissue 
with  dee})  patches  scatteivd  throughout  it.  At  first  sight  it  reminds  one  of  a 
malignant  growth,  but  on  careful  study  we  find  deeply  staining  bunches  of 
17 


258  :\IV().MATA    OK    THK    ITHIU.S. 

iiuisclc-lihcis  lyiiiii:  in  the  hyaline  tissue.  In  fact,  we  have  a  most  typical  example 
of  diffuse  iiyaline  t i-ansformation  of  a  myoma.  Sections  from  the  endometrium 
show  that  the  surface  is  covered  with  polymorphonuclear  leukocytes,  that  the 
surface  e))itheliiim  is  fiattened,  and  that  the  underlying  stroma  shows  a  great 
deal  of  small-round-celled  infiltration.  W'e  have  here  a  chronic  inflammation 
of  the  cervix  with  dilatation  of  the  capillai'ies.  One  of  the  tubes  shows  a 
typical  follicular  hydrosalpinx. 

Gyn.  No.  11949.     Path.  No.  8351. 

A  1  a  r  ti  e  interstitial  m  y  0  m  a  showing  cell  changes 
strongly    suggestive   of    sarcomatous    transformation. 

M.  S.  K.,  white,  aged  thirty-nine,  married.  Admitted  March  8,  1905;  dis- 
charged six  weeks  later.     The  menses  have  always  been  regular. 

Operation.  Hysteromyomectomy,  double  salpingectomy,  right  oophorec- 
tomy. The  uterus  is  considerably  enlarged,  owing  to  the  presence  of  a  large 
myoma  that  springs  from  its  posterior  surface.  The  rectum  is  adherent  to  the 
])(3Sterior  smface  of  the  uterus  near  the  cervix.  It  is  easily  freed.  Hysterec- 
tomy was  performed  without  any  difficulty.  The  patient  made  a  very  satisfac- 
tory recovery.     The  highest  i)ostoperative  temperature  was  100°  F. 

Path.  No.  8351.  The  specimen  consists  of  the  uterus,  the  right  tube  and 
ovar\',  and  the  left  tube.  The  uterus  is  approximately  21  cm.  from  before  back- 
ward, 17  cm.  in  length,  and  12  cm.  in  breadth.  The  great  increase  in  size  is  due 
to  the  ])resence  of  a  myoma,  15  x  11  cm.,  situated  in  the  posterior  wall.  The 
anterior  uterine  A\-all  varies  from  1.5  to  2.5  cm.  in  thickness.  It  shows  diffuse 
myomatous  thickening.  The  uterine  cavity  is  5  cm.  in  length.  The  mucosa 
in  the  thicker  portions  reaches  5  mm.  in  thickness.  The  appendages  show 
nothing  of  interest. 

Histologic  examination  shows  that  some  of  the  cervical  glands  are  enlarged, 
but  otherwise  are  normal.  The  surface  epithelium  is  intact.  The  glands  are 
more  convoluted  than  usual:  they  show  a  slight  tendency  toward  hypertrophy, 
and  here  and  there  can  be  traced  for  some  distance  into  the  muscle.  Sections 
from  the  myoma  show  diffuse  hyaline  degeneration.  In  some  places,  how- 
ever, the  nuclei  are  five  or  six  times  the  natural  size;  they  are  irregular  and  stain 
deeply.  At  one  point  we  may  have  two  or  three  miclei  bunched  together,  while 
at  other  places  the  nuclei  are  of  the  usual  type,  and  about  twice  the  natural 
length  and  breadth,  and  stain  deeply.  In  a  few  areas  the  cells  seem  to  have  a 
very  wild  look:  in  other  woi-ds,  they  are  more  active  than  usual.  In  others 
the  nuclei  are  twice  the  normal  length  and  three  tim(>s  the  normal  breadth,  and 
appear  irregular.  In  some  ])laces  the  nuclei  are  irregularly  triangular,  stain 
deeply,  and  are  fully  tour  oi-  five  times  larger  than  those  that  surround  them. 

In  this  case  we  have  an  atypical  myomatous  growth.  The  cell  changes  are 
most  suspicious  of  a  commencing  sarcoma  developing  from  the  nuiscle.  Were  it 
possible  clinically  to  remove  a  section  of  a  myoma  without  taking  out  the  entire 


MYOSARCOMA    OF   THE    UTERUS.  259 

growth,  and  had  wc  found  such  suspicious  clianges,  we  would  certainly  have 
advised  immediate  removal  of  the  uterus  in  its  entirety.  In  this  case,  of  course, 
the  uterus  with  the  myoma  has  been  removed,  and  if  the  growth  is  actually 
commencing  sarcoma,  we  have  in  all  probability  eliminated  the  process,  as  it 
seems  too  early  for  metastases. 

San.  No.  1973.     Path.  No.  9129. 

8  u  b  p  e  r  i  t  o  n  e  a  1  and  interstitial  u  t  e  r  i  n  e  m  y  o  m  a  t  a  , 
suspicious  altera  t  ions  in  the  m  u  s  c  1  e  -  fi  b  e  r  s  of  the 
myoma  strongly  suggesting  sarcomatous  t  r  a  n  s  f  o  r  m  a  - 
t  i  0  n  . 

E.  H.  S.,  white,  aged  twenty-nine,  married.  Admitted  October  17:  dis- 
charged December  1,  1905.  The  patient  has  had  no  children  and  no  miscar- 
riages.    She  is  a  frail  woman:  the  hemoglobin  is  75  per  cent. 

Operation.  Supravaginal  hysteromyomectomy.  The  highest  temperature 
was  100.4°  F.     Recovery  was  uninterrupted. 

Path.  No.  9129.  The  specimen  consists  of  an  enlarged  uterus,  with  the 
tubes  and  ovaries  attached.  The  uterus,  which  is  multinodular,  is  15  cm.  in 
length,  11  cm.  from  side  to  side,  12  cm.  in  its  anteroposterior  diameter.  It  is 
riddled  with  nodules,  subperitoneal,  interstitial,  and  submucous.  The  uterine 
mucosa  varies  from  2  to  6  mm.  in  thickness.  The  appendages  are  normal.  On 
section,  the  largest  myoma  shows  a  moderate  amount  of  disintegration. 

Histologic  Examination. — Sections  from  the  endometrium  show  that  the 
mucosa  is  greatly  thickened.  The  glands  themselves  are  perfectly  normal, 
although  they  show  a  slight  tendency  toward  hypertrophy.  The  superficial 
portions  of  the  mucosa  show  marked  edema.  Sections  from  the  large  myoma 
show  marked  hyaline  degeneration  and  considerable  li([uefaction.  Here  and 
there  throughout  the  liquefied  areas  are  deeply  staining  nuclei  and  nuclei  two  or 
three  times  the  natural  size.  On  examination  of  further  sections  we  note  the 
appearance  of  unrest  in  the  myomatous  tissue.  On  careful  examination  of  the 
muscle-cells  the  majority  are  found  to  be  swollen  endothelial  cells  of  the  capillaries, 
w^hich  stain  rather  deeply.  There  arc,  however,  nuclei  that  are  twic(>  the  natural 
size  and  stain  intensely.  Then,  here  and  there,  are  bunches  of  two  or  three 
nuclei,  also  staining  rather  deeply,  antl  masses  of  jjrotoplasm  containing  six 
or  seven  nuclei  in  a  row.  The  {)icture  is,  on  the  whole,  rather  susjjicious,  but 
the  cell  alterations  are  not  suthciently  marked  to  enable  us  to  say  i>ositively 
that  there  is  any  malignant  change.  Furthermore,  at  no  point  do  we  find  evi- 
dence (jf  nuclear  diN'ision.  "We  should  l)e  inclin('(l  to  look  upon  this  as  a  benign 
myoma,  but  from  a  clinical  stan(li)oint  would  adxisc  removal  of  the  uterus. 
The  appearance  in  this  case  is  another  link  in  the  chain  that  suggests  to  us  most 
strongly  the  I'ole  a])])ai'entl\'  played  !)>■  hyaline  transformation  and  liiiuefaction 
in  a  sarcoma  develoj)ing  in  a  myoma.  The  muscle-libers  are  sepai'ated  fi'oni  each 
other  and  are  loosened  up,  the.^e  changes  affording  them  an  increased  chance 
of  undergoing  further  development,  in  other  words,  of  becoming  larger. 


260  AIYOMATA    OF   THE    ITERUS. 

Gyn.  No.  12297.     Path.  No.  8887. 

Suspicious  histologic  changes  in  a  subperitoneal 
myoma  which  has  been  shelled  out  of  the  uterus. 

y.  McC,  white,  aged  thirty-two,  married.  The  patient's  menstrual  periods 
have  been  perfectly  regular,  and  she  has  had  eleven  children,  but  no  miscarriages. 
Urination  has  been  increased  in  frequency  for  the  last  four  months.  About  two 
months  ago  she  noticed  some  abdominal  enhirgement,  but  has  had  no  marked 
discomfort,  except  pain  in  the  lower  abdomen  at  night.  There  has  been  slight 
fever,  but  no  nausea  or  vomiting. 

Operation.  Myomectomy  and  appendectomy.  There  were  five  myomata; 
the  large  one  was  pedunculated;  all  were  removed  without  difficulty.  The 
patient  made  a  very  satisfactory  recovery. 

Path.  No.  8887.  The  specimen  consists  of  five  myomata,  the  largest  15  x  9  x  6 
cm.  It  is  markedly  lobulated,  but  is  smooth  and  glistening.  At  one  point  there 
is  a  raw  area,  4  x  2.5  cm.,  corresponding  to  the  uterine  attachment.  On  section, 
this  myoma,  over  an  area  3  cm.  in  diameter,  presents  a  dark-mottled  appearance. 
There  is  considerable  softening;  in  fact,  the  tissue  is  porous-like.  This  shows 
how  difficult  it  is  to  tell  at  operation  whether  or  not  the  myoma  is  undergoing 
degeneration,  although  in  this  case  the  area  of  degeneration  reaches  to  within 
2  mm.  of  the  surface.  In  a  very  short  time  the  omentum  would  have  become 
adherent,  and  l)efore  long  the  uterine  attachment  would  have  been  very  small. 
The  other  nodules  are  quite  small,  the  largest  one  being  2.5  cm.  in  diameter;  they 
offer  nothing  of  interest. 

Histologic  Examination. — Certain  portions  of  the  large  tumor  show  distinct 
hyaline  degeneration.  There  are  also  areas  of  coagulation  necrosis,  with  here 
and  there  quite  a  number  of  pohmorphonuclear  leukocytes.  Some  areas  of  the 
myomatous  muscle  are  strikingly  well  ])reserved,  considering  the  degeneration. 
There  is  no  definite  clue  as  to  any  marked  sarcomatous  changes,  but  one  gets  the 
general  impression  that  there  is  a  slight  tendency  toward  malignancy, 

C.  H.  I.  No.  686.     Path.  No.  8829. 

Interstitial  and  sub  111  u  c  o  us  u  t  c  r  i  n  e  m  y  o  m  a  t  a  ;  s  u  b  - 
m  u  c  o  u  s  m  y  o  m  a  u  11  d  c  i'  g  o  i  n  g  hyaline  changes  and  d  i  s  - 
i  n  t  ('  g  r  a  t  i  0  n  ,  a  n  tl  p  r  e  s  e  n  t  i  n  g  a  j)  i  c  t  u  r  e  t  h  a  t  m  i  g  h  t 
readily   b  e  mist  a  k  e  n  f  o  r  s  a  r  c  o  m  a  . 

H.  ^^'.,  white,  aged  forty-two,  married.  Admitted  July  3;  discharged 
July  30.  1905. 

Operation,  alxlominal  hysterectomy  and  appendectomy.  The  patient  made 
an  uninterrupted  recovery.  Her  highest  postoperative  temperature  was  101.4° 
F.,  twent^'-four  hours  after  operation. 

Path.  Xo.  SS29.  The  six'ciiiicn  consists  of  a  myomatous  uterus  and  of  the 
apjx'iidix.  The  uterus  is  Ki  cm.  l)road,  12  cm.  in  length,  and  16  cm.  in  its  antero- 
posterior diameter.     The  increase  in  size  is  due  to  the  presence  of  a  myoma,  8  cm. 


MYOSARCOMA    OF    THP:    UTERUS.  261 

in  diameter,  occupying  the  posterior  wall,  and  also  of  numerous  smaller  nodules. 
The  uterine  cavity  is  distorted  b}^  a  myoma  which  projects  into  it  and  com- 
pletely fills  it.  The  mucosa  covering  this  myoma  varies  from  2  to  3  nun.  in 
thickness. 

Histologic  Examination. — In  sections  from  the  endometrium  the  cervical 
glands  are  somewhat  dilated.  The  epithelium  lining  the  body  of  the  uterus  is 
intact,  the  glands  are  normal,  and  show  some  tendency  to  extend  into  the  depth. 

The  myoma  projecting  into  the  uterine  cavity  shows  a  great  deal  of  hyaline 
degeneration,  especially  in  its  superficial  portion,  and  the  degeneration  is  of  such 
a  character  that  one  might  readily  mistake  the  remaining  fibers  for  an  infiltra- 
tion by  a  new-growth.  Portions  of  the  myoma  have  undergone  complete 
coagulation  necrosis.  In  the  suspicious  areas  there  is  a  great  deal  of  fibrous 
tissue,  and  then  swollen  islands  of  muscle-fibers  which  stand  out  sharply  in  the 
tissue  and  give  a  suspicious  appearance.  The  changes  are  due  entirely  to  hyaline 
degeneration  and  disintegration,  and  we  do  not  for  a  moment  think  thiit  there 
is  any  sarcoma. 


CHAPTER  X\'. 
CARCINOMA  OF  THE  CERVIX  ASSOCIATED  WITH  UTERINE  MYOMATA. 

Myomatous  growths  suj)i)ly  about  one-eighth  of  the  pathologic  conditions  in 
gynecologic  work,  and  carcinoma  of  the  cervix  is  by  no  means  rare.  Hence 
it  is  perfectly  natural  that  the  two  conditions  should  occasionally  be  met  with  in 
the  sani(>  individual.  In  discussing  the  association  of  the  two  diseases,  it  is  not 
our  intention  to  include  the  cases  in  which  only  very  small  myomata  existed,  but 
chiefly  those  in  which  the  presence  of  the  myomata*  caused  a  material  increase 
in  the  size  of  the  uterus. 

In  "  Adenomyoma  of  the  I'terus"  (p.  206)  six  cases  of  squamous-celled  car- 
cinoma of  the  cervix  associated  with  adenomyoma  of  the  body  are  described. 
In  Chapter  XXTII  two  autopsies  on  patients  suffering  from  carcinoma  of  the 
cervix  and  uterine  myomata  are  given  in  detail. 

In  addition  to  these  8  cases,  we  have  had  10  others — making  18  in  all — in 
which  the  myomatous  uterus  was  also  the  seat  of  carcinoma  of  the  cervix. 

In  Case  4007,  in  which  the  carcinoma  of  the  cervix  was  well  marked  (Fig. 
170,  ]).  2()5),  there  was  a  subnmcous  myoma  4  cm.  in  diameter. 

The  uterus  in  Case  1135  was  densely  adherent  and  contained  a  myoma  5  cm. 
in  diameter.     A  carcinoma  of  the  cervix  had  extended  to  both  broad  ligaments. 

In  Case  7086  the  uterus  was  the  seat  of  far-advanced  carcinoma  of  the  cervix, 
and  the  fundus  contained  an  interstitial  myoma  5  cm.  in  diameter.  A  successful 
abdominal  hysterectomy  was  performed. 

In  Case  9004  the  cervix  was  occupied  by  a  fungating  carcinomatous  mass. 
The  body  of  the  uterus,  owing  to  the  presence  of  myomata,  was  four  times  its 
natvu'al  size.  It  was  densely  adherent.  A  successful  panhystcrectomv  was 
performed. 

In  (!yn.  No.  112Uo  a  hard,  movable  myoma,  the  size  of  a  child's  head,  rose 
from  the  pelvis  and  extended  almost  to  th(^  umbilicus.  The  cervix  had  been 
replaced  by  a  fi-iable  growth  which  involved  the  vagina  on  all  sides  and  extended 
to  the  broad  ligaments.  The  di.-;ease  was  too  far  advanced  to  warrant  operative 
interference. 

In  Case  7819  (Fig.  171,  p.  2()S)  the  cervix  was  occupied  by  a  far-advanced 
carcinomatous  tumor.  The  uterus  C(jntained  an  interstitial  and  pai'tly  sub- 
mucous myoma,  nearly  5  cm.  in  diameter.     Its  outer  surface  had  undergone 

*  In  Ca.ses  5498,  6062,  7428,  7.304,  7N4U,  12:313,  12()1(),  in  which  carcinoma  of  the  cervix  was 
found,  myomata  varying  from  the  size  of  a  pea  to  that  of  a  walnut  w^re  also  present.  In  these 
cases  the  myomata  were  too  small  to  have  much  clinical  significance. 

262 


CARCINOMA    OF   THE    CERVIX    ASSOCIATED    WITH    UTERINE    MYOMATA.  263 


Fui.  169.— Squamous-celled  Carcinoma  of  the  Cervix;  SuBPERiTONEAt,  am.  Imiusthmi.  M^.imm  \,  l)orni.E 
PyosAi.i'iNx;    Cyst  ok  Left  Ovary,     (i  ilhiiii.) 

Gyn.  No.  13050.  I'ath.  No.  10077.  The  piitieiit  \v:i.s  colored,  aged  forty-lhree,  aiil  h:i.l  ii.-vcr  lic.-n  i.rcKiiuiit . 
Abdominal  hysteiectoiuy  was  porfortued.     She  made  a  .satisfactory  recovery. 

The  cervix  is  occupied  by  a  ty|.ical  carciiiomatovis  urowth,  and  surroundiiiK  it  is  a  cutT  of  vaginal  mucosa. 
The  body  of  the  uterus  is  studded  with  myomala,  the  Wirgest  of  which  is  C.  x  7  cm.  .Mtached  to  one  of  the  nodules 
is  an  omental  adhesion  which  carries  .several  vessels  to  the  tumor.  Itxli  l:ill..i.ian  i.flM-  an-  (died  with  pus.  and 
the  left  ovary  contains  a  small  cyst. 


264  MYOMATA    OF   THE    UTERUS. 

coini)lete  calcification,  tlic  calcareous  material  foniiiiig  a  mantle  averaging  1  to 
2  nun.  in  thickness. 

In  the  following  cases  onlv  the  salient  features  are  detailed. 


Gyn.  No.  1135. 

Carcinoma  of  the  cervix,  myoma  in  the  body  of 
the     uterus. 

H.  W..  wliitc.  married,  aged  forty-seven.  Admitted  December  IS,  1891; 
discharged  January  20.  1892.  The  patient  has  been  married  twenty-four 
years  ami  has  had  four  children.  The  menses  commenced  at  thirteen,  were 
regular,  lasting  three  tlays,  and  accompanied  by  some  pain.  She  has  had  quite 
a  profuse  leukorrhea  for  one  year. 

On  vaginal  examination  the  outlet  was  found  to  be  relaxed ;  the  cervix  was  the 
seat  of  a  carcinomatous  growth.    There  was  induration  in  both  broad  ligaments. 

Operation,  December.  13,  1891.     Vaginal  hystero myomectomy. 

A  myoma,  5  cm.  in  diameter,  was  found  in  the  ])ody.  Con.siderable  diffi- 
culty was  experienced  in  removing  the  uterus  on  account  of  dense  adhesions. 
The  temperature  rose  to  100.3°  F.  on  the  first  and  second  days,  after  which 
it  fell  to  normal.  The  patient  was  discharged  apparently  well.  Later,  however, 
she  had  a  recurrence,  and  died  in  February,  1893. 

Gyn.  No.  7086.      Path.  Nos.  3373  and  3390. 

S  q  u  a  m  o  u  s  -  c  ('  1  1  c  d  carcinoma  of  the  cervix;  inter- 
stitial   m  y  o  m  a    of    the   bo  d  }'    o  f    t  h  c    u  t  e  r  u  s  . 

C.  H.,  white,  married,  aged  sixty.  Admitted  July  20;  discharged  August 
31,  1899.  The  patient  has  had  three  children.  The  menopause  occurred  at 
forty-nine.  For  six  months  the  patient  has  had  a  bloody  discharge,  moderate 
in  amount,  occurring  every  few  days.  On  ether  examination  the  outlet  is  found 
to  ])('  decidedly  relaxed.  The  vagina  is  fined  \nth  a  dark,  necrotic  looking, 
foul-smelling  material.  l''rom  the  cerxdx  projects  a  mushroom-like  growth,  which 
is  dark  brown,  mottled  in  ai)pearance,  and  somewhat  necrotic.  It  breaks  down 
readily  under  the  examining  finger. 

The  cer\dcal  growth  was  first  curetted  away  on  August  31.  1899,  and  a  pan- 
hysterectomy with  enucleation  of  the  glands  was  done.  The  disease  extended 
on  the  left  side  out  into  the  broad  ligament.  The  patient  made  a  very  satisfactory 
recovery. 

Path.  No.  3373.  Examination  of  the  tissue  removed  from  the  cervix  shows 
that  it  is  a  typical  squamous-celled  carcinoma. 

Path.  No.  3390.  The  .specimen  consists  of  the  uterus,  tubes,  ovaries,  and 
several  lymph-glands.  The  uteius  is  11  x  G  x  (3  cm.  The  cer\'ix  is  dense  and 
brawny,  and  to  the  touch  feels  like  a  hard,  twisted  rope.  The  os  pre.sents  a 
funnel-.shaped  depression,  which  implicates  the  entire  cerxdx.     The   fundus  is 


CARCINOMA    OF   THE    CERVIX    ASSOCIATED    AVITH    UTERINE    ^lYOMATA. 


265 


irregular  and  globular  in  form,  anil  on  section  an  interstitial  myoma,  5  cm.  in 
diameter,  is  found,  which  has  distorted  the  uterine  cavity  considerably.  The 
uterine  cavity  is  approximately  7  cm.  in  length;  at  the  fundus,  3  cm.  in  breadth. 
The  lymph-glands  removed  show  no  microscopic  evidence  of  carcinoma. 

Gyn.  No.  4607.     Path.  No.  1304. 

Early  s  c|  u  a  in  o  u  s  -  c  e  1 1  e  d  carcinoma  of  the  cervix 
and  s  u  1^  m  u  c  o  u  s  m  y  o  m  a  o  f  the  body  of  the  u  t  e  r  u  s 
(Fig.  170)  . 

L.  D.,  married,   white,   aged  forty-five.     Admitted  August   20;   died  Sep- 


c  a  re  1  n  o  ma 

Fig.  170. — Squamois-cki.i.ki)  C.mici.nom  v  ok  tiii:  Ckrvix  and  SuHMrrors  Myoma  ok  tiik  Hodv  ok  tiik  riKius. 

(0  nat.  size.) 
Gyn.  No.  4607.     The  cervix  is  the  seat  of  an  early  carcinoma,  wliicli  nii^;lil  li.ni'  ln'cn  iT:i.iil\   nviMln.ikcil  at 
operation.     Projecting  into  the  uterine  cavity  is  a  myoma,  4  cm.  in  iliamctcr;    a  >iiliinu<'iius  mynma  is  iniiicalcii 
by  M. 


tember  1,  bSOG.  The  patient  has  l)een  married  (wenty-onc  yc:iis,  and  lias  had 
six  children  and  one  miscarriage.  The  meii.^es  were  icuuImi-  until  the  last  two 
years.  Since  then  they  have  been  profuse,  ahnost  coiitinuous.  and  offensive 
in  odor.     About  a  year  and  a  Imlf  ;igo  she  had  an  attack  of  a|)|)('ii(licitis. 


266  MYO.MATA    OF    THE    UTKRUS. 

Oi)eniti()n.  August  31,  1S96.  Panhysterectomy.  Vagiual*  hysterectomy 
was  exceed iii.uly  didicuh  on  account  of  the  hip-joint  (Usease  from  which  the 
l)atient  was  suffering.  At  the  end  of  the  opei-ation  the  patient's  pulse  could 
scarcely  be  felt.  There  had  been  considerable  loss  of  blood  during  the  opera- 
tion.    She  never  rallied,  and  died  twelve  hours  later. 

Path.  No.  1304.  The  sjx'ciincn  consists  of  the  uterus  with  its  left  appendages 
intact.  The  uterus  is  1()-  cm.  long,  8  cm.  broad,  and  8  cm.  in  its  anteroposterior 
diameter  (Fig.  170).  Its  surface  is  covered  with  dense  vascular  adhesions. 
On  tlic  anterior  surface  is  a  small  myoma,  7  mm.  indiameter.  The  cervix  is  3  cm. 
in  diameter,  and  is  exceedingly  firm  and  resistant.  The  jjosterior  cervical  lip 
is  somewhat  everted.  The  vaginal  portion  is  smooth,  but  the  cervical  ])orti()n 
presents  a  roughened  and  granular  surface.  The  anterior  lip  has  an  ulceratetl 
area  in  its  left  side,  from  the  floor  of  which  stand  out  many  delicate  papillary 
projections.  The  uterine  cavity  is  5.5.  x  4.5  cm.  Projecting  into  the  cavity  is  a 
subnuicous  myoma,  4  cm.  in  diameter.  Over  this  the  nmcosa  is  markedly 
atrophied.  .Microsco})ically,  sections  from  the  cervix  show  the  typical  picture 
of  s([uam()us-celled  carcinoma.  The  uterine  mucosa  over  the  submucous  myoma 
is  much  thinned  out,  but  is  otherwise  normal. 

Gyn.  No.  9004.     Path.  Nos.  5176  and  5223. 

S  ( I  u  a  m  o  u  s  -  c  e  1 1  e  d  carcinoma  of  t  h  e  c  e  r  v  i  x  ;  m  y  o  m  a  t  a 
of   the   body   of   the   uterus;  pelvic   adhesions. 

M.  W.,  aged  forty-nine,  black.  Admitted  August  22;  discharged  October 
15,  1901.  Complaint,  uterine  hemorrhages.  The  menses  began  at  fourteen  and 
were  perfectly  regular,  lasting  from  five  to  six  days,  until  thirteen  months  ago. 
Since  then  the  patient  has  had  a  slight  continuous  Ijleeding  ])ractically  every  day. 
Occa.sionally  the  discharge  is  rather  free  and  contains  numerous  clots.  On  two 
occasions  she  has  had  a  sudden  sharp  hemorrhage,  losing  a  pint  or  more.  She 
has  had  three  children,  the  youngest  nine  years  of  age.  Recently  the  patient 
has  lost  from  fifty  to  sixty  pounds.  For  two  weeks  she  has  been  so  weak  that  she 
has  been  unal)le  to  do  any  work.  She  is  very  anemic;  the  hemogloinn  is  34 
per  cent.  On  vaginal  examination  the  cervix  is  nodular  and  hard,  one  of  the 
nodules  l)eing  fully  3  cm.  in  diameter.  The  uterus  is  in  the  midline,  the  size 
of  that  of  a  four  months'  pregnancy,  and  very  adherent. 

Operation.  The  cervix  was  first  curetted.  Several  days  later  a  vaginal 
hysterectomy  was  performed.  The  patient  rapidly  recovered,  and  left  the 
hospital  in  good  condition. 

Path.  No.  5176.     The  growth  is  a  sfpiamous-celled  carcinoma  of  the  cervix. 

Gyn,  No.  11 293. 
Carcinoma   of   the   cervix;   large   myoma   of    the   body 
of    the    u  t  e  r  u  s . 

*  Vaginal  hysterectomy  for  carcinoina  is  now  never  employed  by  us  wiien  tlie  alxlominal 
route  can  be  adopted. 


CARCINOMA    OF    THE    CP]RVIX    ASSOCIATED    AVITH    UTERINE    MYOMATA.      267 

L.  D.,  colored,  aged  fifty-five,  married.  Admitted  May  17;  discharged 
May  27, 1904.  The  patient  has  had  four  children,  the  youngest  thirty  years  of  age. 
The  menopause  occurred  at  forty.  For  the  past  thrive  months  the  patient  has 
noticed  a  profuse  discharge  from  the  vagina.  This  at  first  was  whitish  in  color, 
but  lately  has  become  bloody  and  foul-smelling.  During  the  past  two  months 
she  has  complained  of  a  dull  aching  pain  in  the  lower  abdomen,  more  pronounced 
in  the  left  side.  This  has  gradually  increased  in  severity.  The  bowels  have  been 
constipated.  The  abdomen  is  very  lax,  and  extending  up  from  the  pehds  to 
tlie  uml:)ilicus  is  a  hard,  movable  tumor  mass  as  large  as  a  child's  head.  The 
cervix  has  been  replaced  by  a  friable  growth,  which  involves  the  vagina  on  all 
sides  and  extends  out  into  both  broad  ligaments.  Filling  the  pelvis  is  a  large 
multinodular  mass  which  was  detected  through  the  abdomen.  The  disease 
was  too  far  advanced  to  w^arrant  operation. 

Gyn.  No.  7819.     Path.  No.  4074. 

S  c}  u  a  m  o  u  s  -  c  e  1 1  e  d  c  a  r  c  i  n  o  m  a  of  the  cervix  ;  s  u  b  - 
peritoneal  and  interstitial  uterine  m  y  o  m  a  t  a  ;  sub- 
acute    salpingitis     and     peri-oophoritis     ( Fig.  171)  . 

8.  B.,  white,  aged  forty,  married.  Admitted  May  15;  discharged  June  12, 
1900.  Her  father  died  of  cancer  of  the  throat;  otherwise  the  family  history 
is  unimportant.  The  patient  has  been  married  twenty  years  and  has  had  two 
children,  the  youngest  seventeen.  The  labors  were  normal.  Several  weeks 
ago  she  noticed  a  slight  reddish  discharge  and  complained  of  sharp  pain  in  the 
lower  part  of  the  abdomen.  This  pain  has  now  become  localized  on  the  right 
side.  The  attack  was  accompanied  by  nausea  and  vomiting  and  a  feeling  of 
faintness.  The  discharge  has  gradually  increased  in  (juantity  up  to  the  present 
time,  and  has  assumed  a  sanguino-purulent  character.  The  patient  is  pale  and 
poorly  nourished.     Hemoglobin,  35  per  cent. 

Operation,  May  17,  1900.  Panhysterectomy.  The  ])atient  made  a  fairly 
satisfactory  recovery,  and  was  discharged  June  12,  1900. 

Path.  No.  4074.  The  specimen  consists  of  the  uterus,  tubes,  and  ()^■aries. 
The  uterus  measui'es  12  x  8  x  S  cm.  The  ])ostei'i()r  siu'face  is  covered  with  ad- 
hesions, and  on  the  anterior  surface  is  a  very  small  myoma.  Posteriorly,  the 
uterus  presents  a  large  rounded  boss,  very  htird,  which  on  section  ))roves  t(^  be  an 
interstitial  myoma  6  cm.  in  diameter  (Fig.  171).  The  peripheral  portion  has 
undergone  calcification,  and  the  center  shows  coagulation  necrosis.  The  cer\ix 
is  also  enlarged  and  resistant;  it  feels  nodular,  and  is  a})proximately  0  cm.  in 
diameter.  The  vaginal  ])ortion  on  the  right  sitle  is  irregular  in  out  Hue,  but  is 
co^•ere(l  with  smooth  mucosa.  The  eerxix  to  the  left  side  ])reseiits  a  lai'ge.  ci-atei- 
like  area,  3  to  5  cm.  in  diameter,  and  about  .'!  cm.  in  depth.  The  base  of  tiiis 
presents  a  roughened,  granular  surface,  with  here  and  there  masses  of  delicate, 
friable-looking  papilhe.  It  is,  for  t  he  most  part,  surrounded  by  a  band  of  smooth 
vaginal  nuicosa,  but  at  one  {)oint,  for  a  distance  of  I  cm.,  tlie  growth  ap{)arently 


268 


MVO.MATA    OF    THK    UTERUS. 


extends  to  the  cut  Illal•,^■in.  The  cervieal  canal  is  3  cm.  long,  and  posteriorly  is 
lined  with  smooth  nuicosa.  Anteriorly,  however,  the  walls  are  composed  of 
a  new-growth,  and  the  entire  inner  surface  is  ulcerated.  The  cervical  walls 
average  1.5  cm.  in  thickness,  and  are  penetrated  by  the  growth  to  within  less 
than  1  mm.  of  the  outer  surface.  The  cut  surface  of  the  growth  consists  of  a 
y(41owish-white,  gramilar  material,  traversed  by  delicate  fibrous  bands.  The 
gi'owth  has  extcMulcd  to  the  internal  os.     The  uterine  mucosa  is  injected,  but 


Fig.  171. — SijUAMors-rKLLKD  Carcinoma  of  the  Cervix;    Partially  Calcifip;i)  iNTr.itsrniAh  Mvoma  in  the 

Body  of  the  Uterus.     (|  nat.  size.) 
Gyn.  No.  7819.    Path.  No.  4074.     The  cervical  growth  i.s  far  advanced,  and  has  extended  almost  to  the  cut 
surface.     The  interstitial  and  partially  submucous  myoma  is  surrounded  by  a  calcareous  mantle  (a),  easily  recog- 
nized by  its  white,  jagged  contour. 


otherwise  noi'inal.  <  >n  the  right  side  the  tube  and  ovary  ai'e  bound  together  by 
adhesions.  ( )ii  the  left  side  the  a])})endages  are  also  coN'ered  with  dense  adhe- 
sions. 

Microscopically,  the  growth  proves  to  be  a  ,s(|uamous-celled  carcinoma  of  the 
cervix. 

Ill  the  above  cases  the  diagnosis  of  carcinoma  was  perfectly  clear  on  digital 
examination,  but  if  the  physician  had  known  that  myomata  had  existed  for  a 


CARCINOMA    OF    THE    CERVIX    ASSOCIATED    WITH    UTERINE    MYOMATA.        269 

long  time,  he  might  readily  have  supposed  that  the  hemorrhage  and  offensive 
discharge  came  from  one  of  the  nodules  that  had  become  submucous  and  was 
sloughing.  In  all  myoma  cases  in  which  no  operation  is  deemed  necessary  it  is 
advisable  to  make  a  vaginal  examination  from  time  to  time  to  determine  if,  by 
any  chance,  a  carcinoma  of  the  cervix  is  developing. 

Cases  of  Early  Carcinoma  of  the  Cervix  Associated  with  Myomata. 

In  such  cases  the  malignant  growth  of  the  cervix  might  readily  be  overlooked. 
Case  12725  affords  a  striking  example  of  such  a  condition.  The  external  os  was 
slightly  patulous.  The  surface  of  the  cervix  was  a  little  roughened,  but  ''not 
suggestive  of  malignancy."  The  body  of  the  uterus  was  somewhat  enlarged, 
and  slightly  irregular  in  outline.  Vaginal  hysterectomy  was  performed.  An 
interstitial  myoma,  3x3x2  cm.,  was  found  in  the  fundus.  On  removal,  the 
cervix  macroscopically  looked  normal,  but  was  slightly  indurated. 

On  histologic  examination  we  found  the  cervix  the  seat  of  the  earliest  scjua- 
mous-celled  carcinoma  we  have  ever  encountered.  Had  an  abdominal  supra- 
vaginal hysterectomy  been  done  instead  of  total  vaginal  hysterectomy,  we 
would  ere  long  have  had  a  well-marked  carcinoma  of  the  cervix,  and  would 
have  classed  it  as  a  carcinoma  developing  in  the  cervix  after  removal  of  the  myo- 
matous uterus,  whereas  the  growth,  though  clearly  present  at  the  time  of  the 
operation,  would  have  been  overlooked. 

In  Case  2432  the  patient  was  in  a  weakened  condition.  The  pelvis  was  filled 
with  a  large  myomatous  uterus,  to  which  the  omentum  and  bowel  were  adherent. 
Had  hysterectomy  been  attempted,  the  patient  would  have  undoubtedly  died 
on  the  table.     Examination  of  the  cervix  showed  adenocarcinoma. 

In  Case  6330  the  position  of  the  cervix,  which  was  jammed  uj)  behind  the 
symphysis,  rendered  the  detection  of  the  cancer  very  difficult.  The  uterus 
seemed  much  enlarged.  On  examination  under  ether,  however,  the  true  character 
of  the  condition  was  readily  ascertained.  In  the  vagina  were  several  indurated 
areas,  one  of  which  was  apparently  about  to  ulcerate.  The  cervix  was  nuich 
thickened  and  friable,  and  I'eadily  bi'oke  down  uiulcr  the  finger.  Tiie  body  of 
the  uterus  was  the  size  of  a  three  months'  pregnancy,  owing  to  th(>  presence 
of  a  myoma.  Histologic  examination  showed  that  the  cervical  growth  was 
a  squamous-celled  carcinoma. 

In  Case  13015,  in  which  a  multii)licity  of  pathologic  })rocesses  existed,  and 
in  which  a  supravaginal  hysterectomy  was  done,  a  very  small  carcinoma  occupying 
the  upper  part  of  the  cervix  and  lower  i^art  of  the  body  (Fig.  172.  j).  272)  was 
totally  overlooked  until  cxainiiicd  in  the  laboi'alory.  Ibid  the  opcratoc  known 
carcinoma  of  the  cervix  was  {)resent,  however,  it  wonld  have  made  little  differ- 
ence, as  the  independent  and  primary  carcinoma  of  the  ovary  had  already 
given  rise  to  many  metastases  throughout  the  abdominal  cavity,  and  the  op- 
eration was  therefore  merely  palliative,  not  radical.  In  this  case  the  uterus 
contained  numerous  small  myomata.  subperitoneal,  interstitial,  and  submucous. 


270  MYOMATA    OF   THK    TTERIS. 

Gyn.  No.   12725.     Path.  Nos.  9502  and  9546. 

Interstitial  111  y  u  111  a  in  t  h  c  1)  o  d  y  o  f  t  li  c  u  t  c  r  11  s  ;  v  0  r  y 
early    s  q  u  a  ni  u  u  s  -  c  e  1 1  e  d    carcinoma    of    t  h  e    c  e  r  ^'  i  x  . 

S.  C.  E.,  white,  aged  thirty-seven,  married.  Admitted  February  24; 
discharged  March  21,1906.  This  patient  was  admitted  to  the  hospital  several 
years  ago  (Gyn.  No.  5864)  with  a  diagnosis  of  extra-uterine  pregnancy.  After 
operation  she  made  an  uninterrupted  recovery.  The  ])atient  has  been  bleeding 
steadily  for  the  ])ast  two  months  and  has  had  almost  constant  ))ain  in  the  lower 
abdomen  on  both  sides.  On  vaginal  examination  the  cervix  was  found  to 
present  a  peculiar  hardness,  although  there  was  practically  no  breaking  down 
and  although,  as  mentioned  in  the  history,  there  was  no  suggestion  of  malignancy. 
The  body  of  the  uterus  was  considerably  enlarged. 

Operation,  Febiiiary  28,  1906.  A'aginal  hysterectomy.  Convalescence  un- 
eventful. 

Path.  No.  9546.  The  uterus  is  12  cm.  li)ng.  The  cervix  looks  normal. 
Occupying  the  fundus  is  an  interstitial  myoma  3x3x2  cm. 

Histologic  Examination. — Sections  from  the  cervix  show  just  a  few  cells 
beginning  to  proliferate  and  to  invade  the  stroma.  Had  it  not  been  for  the  scrap- 
ing ])rior  to  operation,  it  would  have  been  very  difficult  for  us  to  have  said  with 
ab.solute  certainty  that  we  were  dealing  with  a  malignant  growth.  The  combined 
picture,  however,  leaves  no  doubt  whatever  that  we  have  an  early  squamous- 
cellcd  cai'cinoma. 

Gyn.  No.  2432.     Path.  Nos.   loi  and   119. 

A    m  y  o  m  a  tons    u  t  e  r  u  s  ;    c  a  r  c  i  n  o  m  a    o  f     the    c  e  r  v  i  x  . 

S.  B..  white,  aged  thirty-three,  single.  Admitted  November  28;  died 
December  26,  1893.  Seven  months  before  admission  the  patient  first  noticed 
a  tumor  in  the  lower  abdomen  in  the  left  side,  and  for  the  past  three  weeks  she 
has  been  complaining  of  severe  pain  in  the  pelvis  and  has  been  confined  to  bed. 
During  the  last  few  months  the  periods  have  increased  in  duration  and  the  flow 
has  been  excessive.  Menstruation  has  l)eeii  iiTegular.  The  cervix  was  found 
to  be  the  seat  of  a  carcinomatous  growth. 

Operation,  December  2.  1893.  On  section,  the  pelvis  was  found  filled  with 
a  myomatous  uterus  to  which  the  omentum  and  bowel  were  adherent.  It  was 
impossible  to  attempt  enucleation  on  account  of  the  weak  condition  of  the  patient. 
As  a  palliative  mea.sure  the  uterine  arteries  were  clamped  on  both  sides  and  the 
vagina  was  packed  with  gauze.  The  i)atient  improved  for  a  time,  t  hen  lost  ground 
and  died  DecemlxT  26th.  The  enlargement  of  the  body  of  the  utems  was  caused 
by  nmltiple  myomata.  The  growth  of  the  ceiA'ix  on  histologic  examination 
proved  to  be  a  carcinoma. 

Gyn.  No.  6330.      Path.  No.  2584. 

S  q  u  a  m  o  u  s  -  c  e  1  1  e  d  c  a  r  c  i  n  o  m  a  o  f  t  h  e  c  e  r  \-  i  x  ;  m  y  o  m  a 
in    t  h  {'    b  o  d  v    of    t  h  e    u  t  e  r  u  s  . 


CARCINOMA    OF   THE    CERVIX    ASSOCIATED    WITH    UTERINE    MYOMATA.         271 

M.  M.,  colored,  aged  fort3'-.seven,  married.  Admitted  August  30:  dis- 
charged September  20,  1898.  Complaint,  pain  in  the  lower  abdomen  and  pain- 
ful micturition.  For  the  last  four  months  the  patient  has  had  a  profuse  yellowish, 
offensive  leukorrheal  discharge,  and  for  a  month  has  noticed  a  dull  aching  pain 
in  the  back  and  radiating  down  the  legs.  The  ])ain  at  times  has  been  cramp-like 
in  character.  ^Micturition  has  increased  in  frequenc}',  and  has  been  attended 
with  considerable  pain.  During  this  period  she  has  also  lost  much  weight.  On 
vaginal  examination  the  outlet  is  found  to  be  relaxed.  The  cervix  is  jannned 
up  behind  the  symphysis,  and  the  uterus  is  apparently  much  enlarged,  retroflexed, 
and  immovable.  On  ether  examination  the  exact  condition  of  affairs  is  readily 
ascertained.  The  vagina  is  very  large.  At  the  junction  of  the  anterior  and 
lateral  wall  on  one  side  is  a  thickened  area,  irregular  and  roimded.  about  2.5  cm. 
in  diameter,  rising  above  the  surrounding  tissue.  The  mucous  membrane 
over  this  is  reddened  and  apparently  about  to  ulcerate.  There  is  a  similar 
thickened  area  low  down  in  the  vagina  on  the  left  side,  and  several  smaller  thicken- 
ings on  the  posterior  wall.  The  surface  of  the  cervix  is  roughened  and  readily 
breaks  down  under  the  examining  finger.  The  body  of  the  uterus  is  irregular, 
large,  and  nodular,  the  size  of  a  three  months'  pregnancy,  and  markedly  adherent 
posteriorly.  The  clinical  diagnosis  is  carcinoma  of  the  cervix,  myomatous 
uterus  incarcerated  in  the  pelvis,  secondary  carcinoma  of  the  vaginal  ^^•all.  On 
September  2  the  upper  part  of  the  cervix  was  curetted  away.  The  ai)doinen 
was  opened,  the  incarcerated  myomatous  uterus  freed,  but  the  carcinomatous 
process  in  the  cervix  had  extended  too  far  to  permit  of  removal  of  the  uterus. 

Path.  No.  2584.  Histologic  examination  showed  the  growth  to  l)e  a  typical 
squamous-celled  carcinoma  of  the  cervix. 

Gyn.  No.   13015.     Path.  No.   10033. 

Multiple  a  n  d  s  m  a  11  u  t  e  r  i  n  e  m  y  o  m  a  t  a  ;  p  r  i  m  a  r  y  c  a  r  - 
c  i  n  o  m  a  o  f  the  up  p  e  r  part  of  the  cervix  and  1  o  w  e  r  p  a  r  t 
of  the  b  o  d  y  ;  p  r  i  111  a  i-  y  c  a  r  e  i  n  o  m  a  o  f  t  h  e  o  v  a  r  y  ,  wit  h 
w  i  d  e  -  s  p  r  e  a  d     m  e  t  a  s  t  a  s  e  s    (Fig.  172). 

S.  G.,  white,  married,  aged  fifty-one.  Admitted  .hiiie  16;  discharged 
July  14,1906.  Complaint,  a  tumor  in  the  abdomen.  The  mciioiiause  occurred 
five  or  six  years  ago.  Since  then  there  has  been  no  bleediiii;-.  {•'ifteen  nioiiths 
ago  \hv.  ])atieiit  consulted  her  j)hysi('ian  on  account  of  grij)ing  pain  in  the  abdomen. 
Although  the  pain  was  general  in  character,  it  was  more  marked  in  the  rigiit  side. 
At  this  time  she  found  that  she  had  a  tumor  tiie  size  of  a  list.  Since  then  there 
has  been  a  gradual  abdominal  enlargement.  She  lias  noticeil  some  swelling  of 
the  feet  and  also  enlargement  of  the  veins  on  the  light  side. 

On  section,  several  fjuarts  of  daik-brownish  fluid  escaped  fioin  the  aiidoinen. 
An  ovarian  cyst  was  found  in  the  right  side.  The  small  intestines  e\-erywhere 
were  covered  with  nodules  ]  to  2  mm.  in  diametei',  and  t  he  a])])en(lix  had  siniilai' 
nodules  on  its  surface.     No  tlelinile  metastases  wei'e  found  in  the  oineiituni,  al- 


272 


MYOMATA    OF   THE    UTERUS. 


though  it  was  thifkciiccl  and  its  vessels  were  dihited.  Numerous  small  vessels 
were  attached  to  the  left  ovary.  kSupravaginal  hysterectomy  was  performed. 
The  patient  was  discharged  twenty-three  days  after  operation. 

Path.  No.  10033.  Th(»  uterus  has  been  amputated  through  the  cervix.  It 
is  4.5  cm.  ill  length,  5  cm.  in  breadth,  and  4  cm.  in  its  anteroposterior  diameter. 
It  is  covered  with  adhesions.  On  the  surface  are  several  small  })edunculated 
myomata,  the  largest  1  cm.  in  diameter.  There  is  also  a  small  submucous  myoma 
2  cm.  in  tliameter,  situated  in  the  ])osterior  wall.  The  upper  part  of  the  cervix 
and  the  lower  part  of  th(>  body  are  occupied  by  a  growth  apparently  2  cm.  in 
length.     This  is  porous  in  ap]iearance  and  sugg(^sts  carcinoma.     Occupying  what 


ova 


r  > 


""'  c  i  n  o  m  a.      of 

Fig.  172. — Multipi.k  Small  Uterine  Myomata;    Primary  Carcixoma  of  thk  Ovary;    Primary  Carcinoma 

OF  the  Uterus.  (|  nat.  size.) 
Gyn.  No.  13015.  Path.  No.  10033.  The  specimen  is  seen  from  the  front.  The  uterus  contains  several  myo- 
mata— subperitoneal,  interstitial,  and  submucous.  Occupying  the  upper  part  of  the  cervix  and  the  lower  part 
of  the  body  is  an  early  carcinoma.  This  has  been  cut  through  and  a  portion  left  behind.  The  right  ovary  has 
been  converted  into  a  cystic  tumor  filled  with  papillary  masses,  which  have  at  one  point  perforated  the  cyst-wall 
and  reached  the  peritoneal  surface.  As  mentioned  in  the  history,  wide-spread  metastases  were  found  in  the  abdom- 
inal cavity,     a  is  a  corpus  luteum  which  has  not  ruptured. 


corresponds  to  the  right  ovary  is  a  tumor  14  cm.  in  diameter.  This  is  covered 
with  adhesions,  is  pearly  white  in  appearance,  but  has  areas  of  mottling.  On 
section,  the  cyst  is  found  to  be  partly  cystic,  with  little  masses  projecting  from 
the  surface.  To  a  great  extent,  however,  it  is  solid,  having  cauliflower-like 
masses  projecting  into  the  cavity.  Some  of  these  masses  resemble  ])rain  tissue. 
The  solid  portion  is  5  cm.  in  thickness. 

Histologic  Examination. — The  tumor  of  tlu^  right  ovary  consists  of  masses 
of  papillary  outgrowths  of  all  kinds.  In  sonu^  places  the  glands  are  large,  in 
others  exceedingly  small.  The  gland  epithelium  here  and  there  has  prohferated, 
but,  as  a  rule,  is  well  preserved.  We  have  a  characteristic  picture  of  adeno- 
carcinoma.    The  nuclei  of  the  cells,  on  the  whole,  are  very  uniform. 


CARCINOMA    OF   THE    CERVIX    ASSOCIATED    WITH    UTERINE    MYOMATA.        273 

The  friable  area  in  the  cervix,  suggesting  niahgiiancy,  proves  to  be  carcinoma. 
We  have  glantl-Hke  spaces  hned  with  one  layer  of  very  high  cylindric  epithelium. 
In  some  places  the  glands  are  completely  filled  with  young  secondary  glands, 
and  at  other  points  the  epithcliuni  of  these  secondary  glands  lias  so  proliferated 
that  we  have  masses  of  cells  which,  under  the  low  power,  closely  resemble  epi- 
thelial pearls.  The  individual  epithelial  cells  are  fairly  uniform  in  size.  Here 
and  there,  however,  are  large  vesicular  nuclei,  irregular  nuclei,  and  a  great 
numl)er  of  nuclear  figures.  There  is  a  certain  amount  of  disintegration.  The 
growth  is  an  adenocarcinoma  and  is  apparently  independent  of  the  carcinoma 
of  the  ovaiy.  Along  its  advancing  margins  there  is  considerable  small-round- 
celled  infiltration. 

In  this  case  we  have  multiple  uterine  myomata,  two  malignant  processes, 
one  commencing  in  the  ovary  and  forming  metastases  over  the  surface  of  the 
intestines,  the  other  a  primary  carcinoma  originating  in  the  cervix  and  lower 
part  of  the  body  of  the  uterus. 


IS 


CHAPTER  XVI. 

ADENOCARCINOMA  OF  THE  BODY  OF  THE  UTERUS  ASSOCIATED 
WITH    UTERINE  MYOMATA. 

In  our  examination  of  over  1400  cases  of  myomatous  uteri  adenocarcinoma 
was  detected  in  the  body  of  the  uterus  in  25  cases  (about  1.7  per  cent.) :  Adeno- 
myomata  associated  with  adenocarcinoma  of  the  body  (see  "Adenomyoma 
of  the  Uterus/'  p.  218),  3  cases.  Myoma  and  adenocarcinoma  of  the  uterus 
seen  at  autopsy,  6  cases  (see  p.  404).  Myoma  and  adenocarcinoma  of  the 
body  of  the  uterus,  operated  upon,  16  cases.* 

Clinical  History. — The  accompanying  histories  demonstrate  that  in 
most  of  the  cases  myomata  had  been  present  for  several  years,  that  for 
some  months  or  a  year  before  admission  uterine  hemorrhages  had  been  noted, 
and  that  between  periods  there  had  been  a  watery  and  offensive  vaginal  discharge. 

Color. — In  15  out  of  the  17  cases  in  which  definite  d'dta.  could  be  obtained 
the  patients  were  white. 

Age. — In  17  cases  we  have  data  as  to  the  patient's  age.  The  periotl  at 
which  the  carcinoma  has  l)een  detected  corresponds  to  the  decade  of  hfe 
during  which  carcinoma  of  the  body  of  the  uterus  is  usually  found.  The 
youngest  |)atient  was  thirty:    the  oldest,  sixty-four. 

Between  thirty  and  forty —  2  cases. 
Between  forty  and  fifty  —  5  cases. 
Between  fifty  and  sixty —  S  cases. 
Between  sixty    and  seventy — 2  cases. 

17  cases. 

The  association  of  sterility  with  the  development  of  carcinoma  of  the 
body  of  the  uterus  was  emjjhasized  by  us  scn'eral  years  ago.f  Our  previous 
experience  is  strikingly  supported  by  the  table  on  p.  275. 

Out  of  the  17  patients,  6  were  single  and  o  more  had  never  been  pregnant. 
Of  the  remaining  8  patients,  3  had  had  one  miscarriage  each,  but  had  never  born 
full-term  children.  Thus,  12  out  of  the  17  had  never  been  delivered  of  a  child  at 
term.  The  remaining  5  women  had  given  birth  to  12  children.  Sterility  cer- 
tainly seems  to  be  in  some  way  closely  associates  1  with  the  development  of  adeno- 
carcinoma of  the  body  of  the  uterus. 

*  In  Cases  2832,  32.>S,  and  12771  myomata  ami  adcnocarfinoma  of  the  body  of  the  uterus 
were  found  in  the  same  uterus.  The  myomata  were,  however,  too  .small  to  be  of  any  clinical 
significance,  and  these  ca.se.s  have,  accordingh'.  been  omitted  from  the  tal)le. 

t  Thomas  S.  CuUen,  Cancer  of  the  Uterus,  page  474. 

274 


0 

1 

0 

0 

0 

0 

0 

2 

0 

0 

1 

0 

0 

0 

1 

1 

0 

ADENOCARCINOMA  OF  THE  BODY  OF  THE  UTERUS.  275 

Number  of 
Gyn.  No.  Married  Children  Miscarriages 

San.  No.  1852 Yes  4  0 

10220 Yes  4  1 

10085 No 

9141 No 

1069 No 

1691 No 

4262 Yes  1  0 

5858 No 

5957 Yes 

3295 Yes 

10462 Yes 

10997 No 

9443 Yes 

9012 Yes 

9934 Yes 

K.  C.  H.  I.  Nov.  8,  1900 Yes 

3113 Yes 

12  4 

Gross  Appearances  of  the  Uterus. — ^The  myomata  may  be  situated  in 
any  part  of  the  uterus.  Most  frecjuently  they  are  found  in  the  body,  but 
in  some  cases  are  located  low  down  in  the  cervix.  For  example  in  Fig.  175 
(p.  278)  we  see  a  myomatous  nodule  several  centimeters  in  diameter,  situated 
to  the  side  of  the  cervix.  In  Fig.  182  (p.  290)  the  cervix  is  much  distorted  by  a 
large  myoma,  rendering  it  as  large  as  the  body,  which  is  also  much  increased  in 
size  as  a  result  of  the  carcinoma  combined  with  interstitial  myomatous  nodules. 

In  Fig.  183  (p.  292)  the  uterus  is  several  times  its  natural  size.  Studding 
the  surface  are  numerous  small  myomata,  and  scattered  throughout  the  walls 
are  several  myomatous  growths.  The  chief  increase  in  size  is  due,  however, 
to  a  most  extensive  carcinoma  occupying  every  part  of  the  uterine  cavity. 

The  uterus  shown  in  Fig.  180  (p.  286)  was  several  times  the  usual  size,  ami 
presented  the  characteristic  myomatous  appearance,  but  there  was  a  peculiar 
volcanic  api:)earance  of  the  outer  surface  at  a.  Here,  as  shown  later,  the  carcinoma 
had  penetrated  the  entire  thickne.'^s  of  the  uterine  wall  and  lay  just  beneath  the 
peritoneum. 

Occasionally,  as  in  Case  1091,  in  wliich  the  enlarged  uterus  extended  four 
inches  above  the  pubes,  a  submucous  myoma  was  associated  with  the  carcinoma. 

It  must  he  borne  in  mind  that  in  nearly  e\'ery  case  tlic  myomatous  condition 
partly  or  conij)ietely  obscures  the  ))res(Mice  of  the  carcinoma.  Histologically, 
these  adcnocarcinomata  difTer  in  no  way  whatever  from  uncomijlicated  adeno- 
carcinoma of  the  body  of  the  uterus. 

Diagnosis  of  Adenocarcinoma. — A  glance  through  the  histories  of  the  accom- 
panying cases  will  show  that  in  most  of  them  carcinoma  was  not  suspected  until 
after  removal  of  the  uterus.  Clinically,  uterine  hemorrhages  can  be  causetl  by 
uterine  myomata,  and  when  the  iKMhiles  become  sulnnucous  and  undergo  disin- 
tegration, a  foul  and  at  times  watery  discharge  is  the  natural  accompaniment. 


276 


.MYO.MATA    OF   THK    UTKIUS. 


Ill  such  cases  the  cervix  is  iionual  and  the  enlarged  and  ii're^ular  iitcn'us  jjresents 
the  chanicteristic  luuhilatinu'  contour  of  a  tiiultiiio(hihir  uterus.  As  a  rule,  no 
niahgnant  chanj^c  will  he  found  in  the  uterine  mucosa,  althou<j;h  in  a  certain 
percentage  carcinoma  of  the  hcdy  exists.  Tinie,  in  a  goodly  number  of  cases  cu- 
rettage would  reveal  tlu^  cai'cinoma,  hut  if  we  followed  these  \mv^,  (Hux^ting  would 
be  clone  in  many  cases  in  which  no  carcinoma  exists,  and  in  some  instances,  as,  for 
exani])le,  Case  9141  (Fig.  1S2,  p.  290),  in  which  there  was  a  very  large  cervical 
myoma,  the  uterus  was  so  distorted  that 
it  would  be  almost  imp()ssil)le  to  reach 
all  parts  of  the  uterine  ca\ity  with  the 
curet. 

'  Care. 


Fig.  173. — Adenoc.\rci.noma  of  thk  Body  of  thk  Utkri:s,  Associ.a^ted  with  Mvom.\t.\.  (J  nat.  size.) 
Path.  No.  6811.  This  specimen  was  sent  us  by  Dr.  Paul  Owsley,  of  Chicago,  on  January  25,  1903.  It  is  not 
included  in  our  statistics,  but  is  such  an  excellent  example  that  we  have  had  it  drawn.  Near  the  cervix  is  a  small 
.submucous  myoma.  Occupying  the  upi)er  part  of  the  body  is  an  early  carcinomatous  growth  which  as  yet  has 
not  broken  down.  The  myoma,  occupying  the  left  upper  uterine  wall,  measured  S  cm.  in  diameter.  The  uterus 
also  contained  several  other  nodules. 


Treatment.  The  association  of  adeiujcarcinoma  of  the  bod}'  of  the  uterus 
with  myoma  in  about  1.7  per  cent,  of  the  cases  would  naturally  suggest  total  ab- 
dominal hysterectomy  as  a  routine  proceduic.  We  know  by  experience,  however, 
that  the  supravaginal  am])utation  is  not  only  the  easier  operation,  but  that 
whei-e  the  uterus  is  nuich  enlarged  and  distorted,  it  is  often  the  only  on(>  feasible. 
We  feel  that  in  this  o])ei-ation  there  is  much  h'ss  danger  of  injuring  the  ureters. 
If  the  presence  of  carcinoma  of  the  body  can  l)e  definitely  established  or  is 
relatively  certain,  total  hysterectomy  .should  certainh'  be  performed.     We  are 


ADEXOCARCIXOMA    OF    THE    BODY    OF    THF    I'TERUS. 


277 


still  in  favor  of  the  routine  supravaginal  hysterectomy,  with  the  usual  precaution- 
ary control  measures* — opening  the  uterus  to  determine  if  carcinoma  exists 
and  cutting  open  any  suspicious  ni}-()mata  to  see  if  l)y  chance  sarcomatous  changes 
are  present.  If  malignancy  is  detected,  the  cervix  is  at  once  removed,  ^^^len 
carcinoma  of  the  body  exists,  the  chances  of  infection  and  death  are  consider- 
ably increased  as  a  result  of  the  foul  vaginal  discharge. 


Cases  in  which  Adenocarcinoma  of  the  Body  of  the  Uterus  was  Associated 

WITH  Uterine  Myomata. 

Gyn.  No.  9443.     Path.  No.  5671. 

S  u  b  p  e  r  i  t  o  n  (>  a  1    and     interstitial     m  y  o  m  a  t  a  :     a  d  e  n  o  - 
c  a  r  c  i  n  o  m  a    o  f    t  h  c    f  u  n  d  u  s  ,    p  r  o  b  a  1)  1  >•    o  i'  i  g  i  n  a  t  i  n  g    n  e  a  r 
the         internal       o  s  .        (Fig. 
174)  . 

D.  S.,  aged  sixty-four,  white, 
married.  Admitted  March  4;  dis- 
charged April  12,  1902.  The  meno- 
pause occurred  ten  years  ago.  The 
patient  has  had  two  children;  no 
miscarriages.  For  ten  years  she  has 
had  some  pain  over  the  bladder, 
especially  on  lying  down,  and  more 
recently  has  had  constant  pain,  more 
marked  on  exertion.  Operation, 
March  15th.  l^anhysterectomy.  Re- 
covery. 

Path.  No.  5671.  The  specimen 
consists  of  the  entire  uterus  with  the 
appendages.  The  uterus  is  10  cm.  in 
length,  7  cm.  in  brcadlh.  and  5  cm.  in 
its  anteroposterior  diameter  (Fig. 
174).  The  appendages  ai'e  slightly 
adherent.  Springing  from  the  right 
uterine  horn  is  a  myomatous  nodule, 
3.5  cm.  in  diameter.  The  cervix  ap- 
pears normal.  The  uterine  walls 
vary  from  2  to  2.5  cm.  in  thickness, 
show  diffuse  myomatous  thickening, 
and  contain  some  discrete  myomatous  nodules.  The  mucosn  of  the  cei'vix  in 
the  lower  })art  looks  normal.     ()ccuj)ying  the  upjxT  p;irt  (if  the  eei-\i\,  and  also 

*  Thomas  S.  CuUen,  PJxainiiKition  of  L'teriiie  .Mucos  i  ami  .Myniiiatotis  Xodulos  after  Hystcro- 
myonieotomy  to  Exclude  Malignant  Disease,  Jour.  A.  M.  A.,  Marcli  10,  1906. 


Caret  aoma 


Fic.    174. — <"arcinoma  iwkk    1'aht   ok   the 

HoDV    AND    Fl'I'KR    I'Mll     IH      IHK   CkKVIX;      I'tKRINK 

Myomata.      (i  iiat.  size.) 

Ciyii.  No.  944.3.  Path.  No.  'itul.  Tl»e  Rreater  part 
of  the  uterine  cavity  was  the  seal  of  a  carcinomatous 
growth.  The  uterine  walls  siioweii  <iiffuse  myomatous 
thickeninji  an<l  conlaineil  small  discrete  myomata.  Tlie 
subperitoneal  myoma  was  '.i.'i  cm.  in  (liameter. 


975 


MYOMATA    OP^    THK    UTKRUS. 


Care. 


the  greater  ])art  of  the  uterine  cavity,  is  a  shaggy  growth.  In  some  places  this 
projects  fully  1  cm.  from  the  surface.  The  shagginess  in  places  consists  of  fine 
outgrowths,  but  at  other  points  there  are  little  tongue-like  projections. 

On  histologic  examination  the  growth  in  the  body  of  the  uterus  is  found  to 
consist  of  typical  adenocarcinoma,  ai)parently  of  the  type  that  originates  in  the 
body. 

Hiiiiaiiual  examination  of  such  a  uterus  would  show  that  the  body  is  con- 
siderably enlarged  and  that, 
on  the  surface,  is  a  nodular 
growth.  One  would  at  first 
suppose  that  he  was  deal- 
ing with  a  myomatous 
^^'  ''   "         uterus,  but  curettage  would 

instantly  give  a  pro])er  clue 
as  to  the  diagnosis. 

Gyn.  No.  10220.      Path.  No. 
6418. 

C  e  r  V  i  c  a  1  m  y  o  m  a 
a  s  s  o  c  i  a  t  e  d  ^^■  i  t  h 

a  d  e  n  o  c  a  r  c  i  n  o  m  a  o  f 
t  h  e  b  o  d  y  of  the 
u  t  e  r  u  s    (Fig.   175). 

N.  S.,  white,  married, 
aged  fifty-eight.  Admitted 
January  28:  discharged 
March   -S,    1903. 

The  periods  conunenced 
at  foui'teen  and  w(>re  regu- 
lar, every  four  weeks,  last- 
ing four  or  five  days.     The 

1.  in  diameter,  and  situated  in  the  anterior  wall        meUOpaUSC      OCCUrrcd      SeVeU 
odule  2. .5  cm.  in  diameter.     There  is  some  ilif-  r^i,  .        .     , 


Fig.    175. — Midma    of   thk    Ckrvix  and  CARrixoMA   of  tiif.   Body 
OF  THK  Utkrus.     (Nat.  size.) 
Gyn.   No.   10220.     Path.   No.  6418.     The  myoma  to  the  left   of 
the  cervi.x  wa.s  4  cm. 

was  an  interstitial  nodule  -..j  ^••,.  ^.i  i..,v.wcic. .      inc.c  .=>  .lumc  mi-  rpi  •        ■     i 

fuse    thickening     of     the     uterine    walls,    and    cross-sections    of    the        ycaiS  agO.        lUC   paiieni    naS 
blood-vessels    stand    out    prominently.     The    carcinomatous    growth        J^.,,]      four    children     and     OUC 

She    has    had 


uniformly  occupies  the  iipijer  part  of  the  cavity  and  is  sharply  defineil. 


nad 

miscarriage. 

a  leukorrheal  discharge  for  the  ])ast  year  and  a  half.     This  at  first  was  yellowish 
in  color,  but  later  assumed  a  reddish  tinge. 

Operation,  supravaginal  hysterectomy.  After  removal  of  the  uterus  it  was 
split  open,  and  in  the  fundus  was  found  a  ))olypoid  friable  growth.  The  rest  of 
the  cervix  was  now  removed.     The  i)atieiit  made  a  satisfactory  recovery. 

Path.  No.  641S.  This  specimen  consists  of  the  uterus,  left  tube  and  ovary, 
and  the  remaining  portion  of  the  cervix.  The  jjortion  of  the  uterus  measures 
8  X  fi  X  ()  cm.,  and  is  considcrablv  distorted.     Proiectinii  from  the  anteriorwall 


ADENOCARCINOMA  OF  THE  BODY  OF  THE  UTERUS.  279 

is  an  interstitial  nodule  approximately  2.5  cm.  in  diameter,  and  from  the  side 
of  the  cervix  a  myoma  4  cm.  in  diameter.  The  cervical  canal  forms  a  semilunar 
slit.  The  nmcosa  lining  the  cervix  is  apparently  normal.  Occupying  the  body 
of  the  uterus  is  a  growth  which  in  places  reaches  1  cm.  in  thickness  (Fig.  175). 
It  has  a  shaggy  surface  and  here  and  there  forms  little  polypoid  masses.  It  has 
penetrated  the  uterine  wall  for  a  considerable  distance,  and  has  apparently 
involved  the  mucosa  throughout  the  greater  part  of  the  cavity.  The  left  tube 
and  ovary  show  nothing  of  interest. 

Microscopically,  the  myoma  in  the  anterior  wall  shows  considerable  hyaline 
change.  The  growth  in  the  body  of  the  uterus  is  an  adenocarcinoma.  In  most 
places  the  gland  epithelium  has  i)roliferated  to  such  an  extent,  however,  that  it 
forms  solid  masses,  and  here  and  there  suggests  a  s([uamous-celled  growth. 

From  a  clinical  standpoint  the  condition  might  very  readily  be  mistaken 

for  a  simple  myomatous  uterus.     We  have  to  the  left  of  the  cervix  a  hard  nodule, 

a  typical  myoma,  and  in  the  anterior  wall  just  above  this  a  myomatous  nodule. 

One  would  naturally  suppose  that  the  hemorrhage  had  come  from  the  submucous 

myoma. 

Gyn.  No.   10462.     Path.  Nos.  6685  and  6730. 

Carcinoma  of  the  body  of  the  u  t  e  r  u  s  ,  a  p  p  a  r  e  n  t  1  y 
originating  n  e  a  r  t  h  e  i  n  t  e  r  n  a  1  o  s  ;  s  u  b  p  e  r  i  t  o  n  e  a  1 
m  y  o  m  a  t  a  ;  pelvic  adhesions;  sub  a  c  u  t  e  s  a  1  ])  i  n  g  i  t  i  s 
(Fig.  176). 

K.  S.,  white,  aged  fifty-one,  married.  Admitted  May  5;  discharged  June  1, 
1903.  The  pati(^nt  has  been  married  twenty-five  years  but  has  never  been 
pregnant.  Seven  weeks  ago  she  noticed  a  yellowish  vaginal  discharge.  Six 
weeks  ago  hemorrhage  began  and  has  continued  ever  since.  The  i)atient  is 
rather  emaciated  and  w(>ak.     Hemoglobin,  50  \wr  cent. 

Operation.  The  uterus  was  the  size  of  a  four  months'  pregnancy  and  was 
lifted  upward  with  a  great  deal  of  difficulty  on  account  of  nunici'ous  adhesions. 
On  pressure  it  sutldenly  collapsed  and  a  large  amount  of  necrotic  material  escaj)ed 
from  the  cervix,  suggesting  a  pyometra.  Two  myomatous  nodules  on  the  right 
side  were  adherent  to  the  pelvic  wall,  apparentl>'  causing  a  hydroiiretc^r  on  the 
right  side.  On  account  of  the  subse(|uent  pathologic  findings  the  cervix  was 
removed  two  weeks  later  per  nKjiiKni).  The  patient  was  disehai'ged  t  went\'-fiN'e 
days  after  the  first  operation. 

Path.  Nos.  6()<S5  and  (ITMO.  The  specimen  consists  of  a  inyoinatous  utei'us  am- 
putated through  the  cer\-ix  and  (tf  the  tubes  and  ovaries.  The  utcius  measures 
6  x  5  X  5  cm.  Antei'iorly,  it  is  smooth;  posterioi'ly,  co\-erc(|  with  adhesions. 
Projecting  from  its  surface  are  two  peihuicuJated  niyoniala,  one  (i  \  .")  cm.,  the 
other  somewhat  smaller  (Fig.  176).  These  ai'e  hkewise  eoxcrecl  witli  adhe- 
sions. On  section,  it  is  found  that  nearly  the  entire  cervical  jiortion  of  the 
uterus  and  the  greater  portion  of  \hv  body  is  o('cu])ied  by  a  shaggy  growth, 
which  in  the  cervix  extends  downward  almost  to  the  line  of  incision,  and  has 


280 


-MYo.MATA    OF    THK    ITKRI'S. 


apparently  not  been  entirely  reniox-ed.     The  uterine  wall  above  the  point  of  in- 
vasion varies  from  1  to  2  cm.  in  thiekness. 

Microscopic  sections  show  that  the  i^i-owlh  in  the  uteiiis  is  of  a  glandular 
type.     In  many  places  the  epithelium  has  so  proliferated  that  we  have  solid 

masses  of  cells  closely  resemblinc:  squamous 
epithelium.  The  superficial  jjortions  show 
considerable  disintegration.     The    o;rowth    is 


Fig.  176. — Mli.tipi.k  Uterim;  Mvomata;  Carcinoma  of  the  Lower  Part  oe  the  Body  and  Upper  Portion 

OF  THE  Cervix.     (4  nat.  size.) 
Gyn.  No.  10462.     Path.  Nos.  6685  &  6730.     Before  the  drawing  was  made  the  cervix,  which  was    removed 
later,  was  added  to  the  upper  part  of  the  uterus.     Three  subperitoneal  myomata  are  seen.     The  largest   of  these 
was  6x5  cm.     The  external  os  is  normal  but  the  upper  part  of  the  cervix  and  lower  part  of  the  body  are  occupied 
by  a  shaggy  papillary  adenocarcinomatous  growth. 

an    adenocarcinoma.      Sections    fr(.)m    the    left    tube  near   its   middle   show   a 
moderate  degree  of  subacute  salpingitis. 

This  case  is  interesting  from  a  clinical  standpoint.  The  general  contour  of 
the  uteruS;  with  its  accom])anying  nodules,  strongly  suggests  a  myomatous 
uterus.  The  growth  is  seen  extending  down  to  the  internal  os,  and  might  very 
readily  be  oN'erlooked:  in  fact,  carcinoma  was  not  susjx'cted  until  the  uterus 
had  been   removed. 

San.  No.   1852.      Path.  No.  8347. 

S  u  1)  a  c  u  t  e  i  n  fl  a  m  m  a  t  i  o  n  o  f  t  h  e  c  e  r  \-  i  x  :  a  d  e  n  o  c  a  r  c  i  - 
n  o  m  a  of  t  h  e  b  o  d  y  o  f  t  h  c  u  t  e  r  u  s  :  a  d  r  n  o  111  y  o  m  a  o  f  t  h  e 
1)  0  d  y  o  f  t  h  e  u  t  e  r  u  s  ,  a  11  d  a  n  a  p  p  a  r  e  11  t  1  y  i  n  d  e  {)  e  n  d  e  n  t 
r  o  u  n  d  -  c  e  1 1  e  d    s  a  r  c  o  m  a     o  f     1  h  c    b  o  d  y   o  f     t  h  e    u  t  e  r  u  s  . 

This  case  is  reported  in  detail  in  "  Adciioiiiyoma  of  the  rterus."  j).  225. 


Gyn.  Nos.  3295  and  7699.     Path.  Nos.  582  and  3948. 

S  u  1)  m  u  c  o  II  s     111  y  o  in  a  .     wit  h     a  r  e  as    strongly    suggest- 
ing    s  a  r  c  o  m  a  tons       d  e  g  e  n  e  ration.     Five       years      la  t  e  r 


ADEXOCARCIXU.MA  UF  THE  BODY  OF  THE  UTERUS.  281 

complete  h  y  s  t  e  r  e  c  t  o  in  y  for  c  a  r  c  i  ii  o  m  a  of  t  h  e  1)  o  d  y  o  f 
the    u  t  e  r  ii  s  . 

R.  B.,  aged  forty-five,  married,  white.  Admitted  January  24,  1895.  At 
that  time  the  vagina  was  filled  with  a  smooth,  hard,  conical  mass.  A  myomec- 
tomy was  performed,  and  the  patient  discharged  on  February  23,  1895. 

Histologic  examination  of  the  myoma  showed  changes  very  suggestive  of 
sarcoma. 

The  patient  was  admitted  again  in  April,  1900,  more  than  five  years  later,  and 
the  uterus  removed  on  account  of  a  carcinomatous  growth,  which  occupied  the 
body. 

Path.  No.  3948.  The  specimen  consists  of  the  uterus  with  its  appendages. 
The  uterus  is  somewhat  enlarged,  measuring  13  cm.  in  length,  8  cm.  in  breadth, 
and  6  cm.  in  its  anteroposterior  diameter.  Occupying  the  right  cornu  is  a 
nodule  3  cm.  in  diameter,  which  proves  to  I)e  a  myoma.  The  cervix  has  been 
converted  into  a  mere  shell,  measuring  7  cm.  in  length  and  5  cm.  in  its  antero- 
posterior diameter.  The  internal  os  is  1.7  cm.  wide.  The  lower  2.5  cm.  of  the 
cervical  canal  presents  the  usual  appearances,  but  the  remaining  portion  has  been 
liollowed  out  with  a  curet.  Here  the  surface  is  rough  and  covered  with  a  layer 
of  friable  tissue  and  blood-clots.  Occasionally  long,  finger-like,  papillary  out- 
growths are  seen,  and  where  the  growth  joins  the  uterine  cavity  and  has  not  been 
injured  by  the  curet,  definite  yellowish-white,  very  friable  papillary  masses  an* 
present.  The  Avails  of  the  excavated  portion  of  the  cervix  vary  from  3  to  4  mm. 
in  thickness,  are  indurated,  but  jjreak  down  readily.  The  uterine  cavity  is  3  cm. 
long.  The  mucosa  in  the  upper  portion  is  slightly  injected,  but  smooth.  In  the 
lower  half  of  the  cavity  it  is  gathered  up  into  papillary  masses  continuous  with 
those  of  the  cervical  growth.  Projecting  into  the  uterine  cavity  are  two  small 
polypi.     The  tubes  and  ovaries  are  slightly  adherent,  but  otherwise  normal. 

On  histologic  examination  the  growth  in  the  uterus  proved  to  be  an  adcnio- 
carcinoma,  and  probably  originated  just  above  the  internal  os.  The  uterus, 
besides  containing  the  subjjcritoneal  nodule,  also  had  sinall  interstitial  niyoniata 
scattered  throughout  it. 

In  October,  1902,  the  patient  returned  \\\{\\  an  in()i)('ial)le  growth  in  the 
vagina.  This  case  is  intei'csting  because  the  myoma  which  was  removed  li\-e 
yeai's  before  showed  changes  most  suggestix'e  of  sarcoma.      (See  j).  248.) 

Gyn.  No.  10997.     Path.  No.  7246. 

M  u  1  t  i  |)  1  e  u  t  e  r  i  11  e  m  y  o  tn  a  1  a  ,  s  u  b  ni  u  c  o  u  s,  i  11  t  e  i'  s  t  i  - 
t  i  a  1  ,  and  s  u  1)  p  e  i'  i  t  o  11  e  a  I  :  a  d  e  n  o  c  a  r  c  i  11  o  111  a  i  11  \'  o  1  \'  i  11  g 
f  u  n  d  u  s   and    c  e  i'  \-  i  \    ( l''ig.  1  77). 

B.  A.,  aged  hfty-four,  white,  single.  .Vdinilled  .laiiuai'v  IS;  discharged 
February  27,  1904.  One  sistei-  was  operated  ui)on  in  this  hospital  for  myoma 
some  years  ago.  For  seven  years  the  patient  has  noticed  an  abdominal  tumor. 
Two  years  ago  there  was  considerable  abdominal  pain.     I'or  the  last  year  there 


282 


MYOMATA    OF   THK    ITERUS. 


has  been  a  ooiitinuous  vaginal  discharge,  usually  watery  m  character,  often 
stained  with  blood. 

Operation.  Hysteroniyoinectoniy  with  aiiijHitatioii  through  the  cervix. 
The  endometrium  looked  cai-cinomatcnis,  and  in  conse(iuence  the  entire  cervix 
was  removed.     The  patient   made  a  ])erfect  recovery. 

Path.  No.  724().  The  specimen  consists  of  a  multinochilar  myomatous  uterus, 
16x14x10  cm.  This  has  been  amputated  through  the  cervix.  Anteriorly,  the 
growth  is  free  from  adhesions;  po.steriorly,  these  are  numerous.  Occupying  the 
anterior  wall  is  a  myomatous  nodule  8  cm.  in  diameter  (Fig.  177).  There  is  a 
subperitoneal  myoma  2  cm.  in  diameter,  and  several  others  scattered  throughout 


"^^^f-"' 


Larc- 


Fig.   177. — Mri.iii'i.i:    I   iihim;   Mvdmm^;    Carcixoma  of  the  Body  of  thb  Utkru.s.     (5  nat.  size.) 
Gyn.  No.  10997.    Path.  No.  7246.     The  uterus  contained  several  interstitial  myomata,  the  large.st  of  which 
was  8  cm.  in  diameter.     Lining  the  entire  uterine  cavity  was  a  carcinomatous  growth  that  extended  to  the  i>i>int 
of  amputation.     This  fact  having  been  discovered  at  the  time  of  operation,  the  remainder  of  the  cervix  w:is  at 
once  renifivpfi. 

the  walls.  The  aj){)endages  are  apparently  normal.  ()a  section,  the  cavity  of 
the  uterus  is  found  to  be  irregular  in  shape  and  7  cm.  in  length.  iSurrounding  the 
entire  cavity  from  cei'vix  to  fundus  is  a  fine  ])npillar\'  or  tree-like  growth.  In  the 
cervical  portion  it  is  very  well  outlined  and  ])reserved,  but  in  the  body  it  has  in 
))laces  become  necrotic.  M  no  i)oint  is  there  any  evidence  of  normal  mucosa. 
The  growth  in  certain  places  imolves  the  wall  foi'  a  distance  of  l.o  cm.  It  is 
sharply  outlined  fi-oni  the  uterine  muscle. 

Microscopically,  no  trace  of  normal  mucosa  of  the  cervix  or  of  the  body  is 
found.  The  cavity  of  the  uterus  is  lined  with  an  irregular  growth  of  glands, 
that  in  some  places  show  a  distinct  papillai-y  arrangement.  The  growth  is  a 
ty])ical  adenocarcinoma. 


ADENOCARCIXOMA  O?^  THK  BODY  OF  THK  UTERUS. 


283 


Gyn.  No,  5858.     Path.  No.  2146. 

A  d  e  II  o  c  a  r  c  i  11  o  in  a  o  f  t  h  0  b  o  d  }'  o  f  t  h  c  uterus,  as- 
sociated with  i  n  t  e  r  s  t  i  t  i  a  1  m  y  o  in  a  t  a  ;  c  h  r  o  n  i  e  e  11  d  o  in  e  - 
t  r  i  t  i  s    both    of     body    and    cervix  (Fig.  17S) . 

K.  H.,  aged  forty-seven,  white,  single.  Admitted  February  8,  1898,  com- 
plaining of  pain  ill  the  left  lower  abdomen  and  also  of  uterine  hemorrhage.  For 
two  years  she  has  had  severe  hemorrhages  and  some  vaginal  discharge,  watery  in 


Fi(i.  178. — Adenocarcinoma  of  t:ik  Boi)v  of  thk  Uterus  Associated  with  Interstitim.  Myomata. 

(  }  iKit.  size. ) 

Ciyii.  No.  .'JS.'JS.  I'adi.  No.  2\M>.  The  uterus  is  nearly  twice  its  natural  size  and  is  ijear-shaped.  Siluateil  in 
the  anterior  wall  near  the  fundus  is  a  typieal  myoma,  and  .iust  below  it  a  s:naller  one,  of  the  interstitial  variety. 
The  cervix  is  much  thickened,  hut  retains  its  normal  contour.  The  vaKinal  portion  is  intact.  In  the  gro.ss  .speci- 
men the  cervical  canal  appears  unaltered,  although  a  severe  endometritis  was  present.  The  mucosa  in  the  lower 
part  of  the  uterine  cavity  likewise  presents  the  usual  appearance,  although  here  alsa  there  was  a  most  e.vtensive 
endometritis.  Occupying  the  upper  part  of  the  cavity  is  a  new-growth,  roughly  divided  into  parallel  rows.  These 
vary  in  size  and  have  smooth  surfaces,  in  contradistinction  to  the  delicate,  finger-like  outgrowths  usually  present. 
In  a  few  of  the  crevices  between  the  polypi,  however,  some  of  the  finger-like  processes  are  noted.  'IMie  growth 
averages  1  cm.  in  thickness,  and  has  invaded  the  greatly  thickened  muscular  walls  to  a  slight  extent.  .Macro- 
scopically,  the  api)endages  on  both  sides  apj>ear  to  be  normal,  but  the  tube  on  the  right  side  was  found  to  be  the 
seat  of  an  acute  s.alpingitis,  although  the  fimbriated  extremity  was  palenl.  It  is  almost  certain  that  the  strepto- 
coccic peritonitis  develoix'ii  from  the  discharges  caused  by  the  profuse  cndoinetritis.      (.-\ft<'r  Thomas  S.  Cullen.) 


character,    and    frciiucnt  ly    blood-tiugcd    ;iiid    ort'ciisiNc.     ( )ii    examination    of 
s:'raj)iiigs  the  j)resence  of  adcnorarcinoma  (»!'  I  lie  boily  \\;is  (IclccttMl. 

()j)eration,  February  1L\  1N*.)S.  Panhysterecldiiiy.  The  .adlicicnt  omentum 
having  been  released,  the  uterus  was  removed  in  the  usual  way.  The  ))atient 
developed  a  general  peritonitis  and  (hed  within  twenty-four  hours.  .V  pure 
culture  of  Streptococcus  pyogenes  was  obtained  fi-om  the  abdominal  cavity. 


284  MYOMATA    OF    THE    I'TERl'S. 

rath.  No.  1214().  The  spccinicu  consists  of  the  uIltus,  tubes,  and  ovaries. 
The  uterus  is  11  cm.  in  length,  7  cm.  broad,  and  8  cm.  in  its  anteroposterior 
diameter.  It  is  free  from  adhesions.  Projecting  fi-om  the  anterior  surface  is  a 
rounded  boss  5  cm.  in  diameter.  It  is  firm  in  consistence,  and  on  section  pre- 
sents the  u.sual  myomatous  appearance.  The  vaginal  portion  of  the  cervix 
a])pears  to  be  normal.  The  cervical  portion  is  'A.')  cm.  long,  and  averages  9  mm. 
in  diameter.  The  muco.sa  is  smooth,  but  somewhat  injected.  The  uterine 
cavity  is  5  cm.  in  length,  and  at  the  fundus  reaches  5  cm.  in  breadth.  Occupy- 
ing nearly  the  entire  cavity  is  a  new-growth,  grayish  in  color  (Fig.  178).  It  is 
for  the  most  part  divided  uj)  into  .several  longitudinal  ridges,  separated  by  deep 
furrows.  The  tissue  comj^osing  the  ridges  has  a  smooth  surface,  but  at  several 
points  along  the  advancing  margin  of  the  growth  delicate,  finger-like  processes  are 
visible.  The  downward  extension  of  the  tumor  is  sharply  defined,  the  growth 
overlapping  the  mucous  membrane.  On  an  average  it  is  1  cm.  in  thickness  and 
has  extended  for  about  3  or  4  mm.  into  the  depth.  On  section,  the  tis.sue  of  the 
new-growth  is  seen  to  be  somewhat  friable. 

Histologic  Examination. — The  muco.sa  of  the  cervix  and  that  of  the  body 
not  invaded  by  the  cancer  has  Ix'en  converted  almost  entirely  into  granulation 
tissue,  evidently  as  a  result  of  a  long-standing  infection.  The  patient  was  un- 
doubtedly infected  from  the  uterine  discharge,  the  general  peritonitis  which  so 
soon  caused  her  death  being  readily  accounted  for. 

This  case  is  described  in  detail  in  Cullen's  '"  Cancer  of  the  Uterus."  p.  452. 

Gyn.  No.  5957.     Path.  No.  2238. 

A  large  m  y  o  m  a  t  o  u  s  u  t  e  r  u  s  w  i  t  h  a  d  e  n  o  c  a  r  c  i  n  o  m  a 
of   the    body;    general    pelvic    peritonitis    (Fig.  179). 

8.  B.,  colored,  aged  forty-seven,  married.  Admitted  March  16;  discharged 
April  22,  1898.  Complaint,  al)dominal  tumor.  Her  menses  commenced  at 
thirteen  and  were  always  regular  until  six  years  ago.  She  had  a  mi.scarriage  at 
twenty-three.  Six  years  ago  .she  had  a  fairly  constant  bloody  uterine  discharge, 
alternating  with  a  leukorrheal  flow,  and  about  three  years  later  first  felt  a  small 
lump  in  the  abdomen,  which  has  increa.sed  slowly  in  size.  During  the  last  nine 
months  she  has  had  a  dull,  aching  sensation  in  the  lower  part  of  the  abdomen. 

Operation,  March  21,  1898.  Abdominal  hysten^ctomy.  The  uterus  was 
amputated  through  the  cervix,  cai'cinoma  not  being  suspected  imtil  after  the 
operation  was  coni]:)lete(l. 

Path.  No.  2288.  The  sjiecimeii  consists  of  the  uterus,  which  has  been  con- 
verted into  a  globular  tiunoi-  1 1  cm.  in  diameter,  covered  with  numerous  vascular 
adhesions.  Springing  from  it  are  several  myomata,  some  of  which  are  sessile, 
others  pedunculated.  The  ])ortion  of  the  ceivix  jire.sent  is  2  cm.  in  length;  its 
nmco.sa  presents  the  usual  a))pearance.  The  uterine  walls  vary  from  4  to  8  cm. 
in  thickness,  and  contain  several  myomatous  nodules,  the  largest  being  6  cm.  in 
diameter.     The  uterine  cavitv  is  (]  cm.   long  and  4.5  cm.  broad  at  the  fundus 


ADENOCARCIXO.MA  OF  THE  BODY  OF  THE  UTERUS. 


285 


(Fig.  179j.  The  mucosa  covering  the  posterior  wall  is  smooth  and  glistening  and 
slightly  injected.  Tt  varies  from  1  to  2  mm.  in  thickness.  The  ])ortion  cover- 
ing the  anterior  wall  is  profoundly  altered,  and  now  consists  of  a  new-growth 
averaging  1  cm.  in  thickness.  The  surface,  for  the  most  part,  is  smooth,  but 
occasionally  ])roj(>cting  from  it  is  a  minute,  hnger-like  process,  while  at  several 


■'#^^ 


x-m 


4^ 


»^  K 


Fig.  179. — A  Large  Myomatous  Uterus  Sho\vi.\g  .\i.so  .\n  .\i)e.\ocarcinom.\  of  the  Body,  (i  nat.  size.) 
Gyn.  No.  5957.  Path.  No.  22.38.  The  uterus  is  much  enlarged  and  has  subperitoneal  nodules  projecting;  from 
its  surface.  Situated  in  the  anterior  wall  are  one  large  and  several  smaller  interstitial  myomata.  The  uterus  has  been 
amputated  through  the  cervi.x.  The  mucosa  in  the  lower  part  of  the  uterine  cavity  is  normal,  but  on  being  traced 
upward  several  centimeters  on  the  anterior  wall  it  is  replaced  by  a  new-growth,  which  in  places  is  smooth,  but  at 
most  points  is  covered  with  delicate,  finger-like  oiitgrowths.  The  growth  reaches  1  cm.  in  thickne.ss,  and 
stands  out  in  sharp  contrast  to  the  uterine  muscle,  which  it  has  invaded  to  a  slight  extent.  Upward  it  reaches  to 
the  to))  of  the  uterine  cavity,  its  advancing  margin  being  irregular.  The  mucosa  covering  tlie  posterior  wall  is 
slightly  mottled,  but  otherwise  ajjpears  normal.  The  stumps  of  both  Fallopian  tubes  are  visible  in  the  upper 
part  of  the  picture.  All  the  symptoms  in  this  case  might  readily  have  been  caused  by  the  myomata,  and  without 
curettage  it  would  have  been  impossible  to  diagnose  the  carcinoma.  Had  we  known  that  the  carcinoma  was  i)resent 
in  this  case,  the  uterus  would  have  been  cntiicly  rciiKivcc!  inslcud  n!  licin^  nnipul.'ili'il  llirnugh  the  (-('rvix. 
(After  Thomas  S.  Cullen.) 


points  the  surface  ])resents  a  shaggy  appearance,  due  to  aggregations  of  myriads 
of  these  finger-like  ])rojections.  At  one  point  these  delicate  outgrowths  form  a 
hunch  projecting  fully  1  cm.  from  the  surface.  The  growth,  on  .section,  presents 
a  waxy  appearance,  and  stands  out  in  sh;irp  coiit  last  to  the  muscle  which  it  has 
invaded  for  a  short  distance. 


286 


MYOMATA    OF    THE    UTERUS. 


On  histologic  exaniiuation  the  growth  in  the  body  is  found  to  be  a  typical 
adenocarcinoma. 

This  case  is  describ(Ml  in  detail  in  Cullen's  ''Cancer  of  the  Uterus,"  p.  449. 

K .,  C.  H.  I.     Path.  No.  4479. 
S  u  b  p  e  r  i  t  o  n  e  a  1  .   interstitial,    an  d  s  u  b  in  u  c  o  u  s  myoma- 

t  a  :    e  X  t  e  n  s  i  \'  e     adenocarcinoma     of     the     body     of     the 

ut  erus    (Fig.  180). 

E.  P.  K.,  white,  aged  thirty-eight,  married.     Admitted  to  the  Church  Home 

and  Infirmary  November  8:  died  November  17,  1900.     She  had  one  miscarriage 

nine  years  ago.  In  March, 
1900.  she  had  three  hemor- 
rhages, which  were  severe  and 
showed  large  clots.  Since  then 
there  has  been  frequent  bleed- 
ing, and  lately  a  profuse  leukor- 
rheal  discharge. 

The  uterus  reached  a  point 
midway  between  the  pubes  and 
umbilicus,  and  on  examination 
presented  a  peculiar  appear- 
ance. The  mass  suggested  a 
myoma,  and  yet  there  was  an 
un  e^'ennessof  the  surface — what 
might  be  termed  a  volcanic  ap- 
pearance, the  growth  welling  out 
on  all  sides  and  having  an  um- 
bilicated  center.  The  left  tube 
and  ovary  were  tied  off,  the 
round  ligament  was  controlled, 
and  a  myoma  5  cm.  in  diameter 
was  then  detected  lying  in  the 
broad  ligament.  After  opera- 
tion the  uterus  was  opened  and 
the  malignant  growth  detected, 
and  we  exjjeeted  to  remove  the 
cervix  at  a  later  date. 
For  the  first  day  after  operation  the  patient  did  comparatively  well,  but  then 

commenced  to  show  definite  signs  of  ))eritonitis  and  died  in  a  few  days.     This  case 

shows  the  absolute  neces.sity  of  opening  the  uterus  the  minute  it   is  removed. 

Had  we  followed  out  this  rule,  the  cervix  would  have  been  taken  out  at  once:  we 

would  have  ])lace(l  a  liberal  gauze  drain  in  the  ju'jvis,  and  })rol)ably  have  avoided 


Fig.  180. — Multiple  Uterine  Myomata;  Adknocarcixoma  of 

THE  Body,  with  Extension-  to  thk  PfiRiToxEAL  Surface. 

(i  nat.  size. ) 

K.,  C.H.I.  Path.  \o.  4479.  The  uterus  ha.s  been  amputated 
through  the  cervix,  aiifi  to  the  left  is  a  myoma.  The  body  of 
the  uterus  contains  several  myomatous  nodules.  Over  a  large 
area  (a)  the  tissue  presents  a  volcanic  appearance,  due  to  a  well- 
ing-out  of  the  growth.  On  section,  carcinoma  of  the  body  was 
found,  the  unusual  appearance  of  the  surface  being  due  to  ex- 
tension of  the  growth  by  continuity   t<}  the  peritoneal  surface. 

Had  the  carcinoma  been  suspected  at  operation,  the  cervix 
would,  of  course,  have  been  removed  at  once.  The  cervical 
myoma,  together  with  the  general  contoiir  of  the  uterus, 
would  naturally  suggest  to  the  operator  that  he  was  dealing 
with  an  ordinary  myomatous  uterus. 


ADENOCARCINOMA  OF  THE  BODY  OF  THE  UTERUS.  287 

infection,  which  so  frequently  follows  where  such  a  foul  carcinomatous  growth 
exists. 

Path.  No.  4479.  The  specimen  consists  of  a  large  multinodular  myomatous 
uterus  (Fig.  180).  The  fundus  is  occupied  by  a  large  tumor  mass,  12  x  13  cm., 
developed  more  posteriorly  than  anteriorly.  The  surface  is  generally  smooth. 
On  section  of  the  uterus  the  cavity  is  found  to  be  filled  with  a  carcinoma  of  the 
body,  associated  with  numerous  myomatous  nodules. 

G5m.  No.  4262,     Path.  No.  1137. 

Subperitoneal,  interstitial,  and  submucous  myo- 
mata;  adenocarcinoma  of  the  body  of  the  uterus 
(Fig.  181). 

E.  P.,  aged  thirty,  colored,  married.  Admitted  March  30;  discharged  April 
30,  1896.     The  patient  has  had  one  child  and  no  miscarriages. 

Operation,  April  6,  1896.  Abdominal  hysteromyomectomy  with  amputation 
through  the  cervix.     The  patient  made  an  uninterrupted  recovery. 

Path.  No.  1137.  The  specimen  consists  of  the  uterus  with  its  appendages. 
The  uterus  is  approximately  globular,  measuring  15  x  13  x  13  cm.  Both  ante- 
riorly and  posteriorly  it  is  smooth  and  glistening.  The  portion  of  the  cervix 
present  is  4  cm.  in  diameter.  The  posterior  uterine  wall  varies  from  2.5  to  3  cm. 
in  thickness,  and  scattered  throughout  it  are  several  myomata,  some  of  which 
are  interstitial,  others  sessile.  The  anterior  wall  varies  from  2  to  9  cm.  in  thick- 
ness; besides  containing  several  small  myomata,  it  is  occupied  l)y  a  sul)mucous 
myoma  8  cm.  in  diameter.  The  uterine  cavity  is  8  cm.  in  length,  and  at  the 
fundus  7.5  cm.  in  breadth.  The  mucosa  at  the  fundus  varies  from  2  to  3  mm.  in 
thickness,  but  the  greater  part  of  that  covering  the  anterior  wall  and  also  that 
on  the  posterior  wall  presents  a  markedly  altered  appearance,  being  gathcMx^l  up 
into  large  and  small  tongue-like  folds,  varying  from  0.3  to  1.5  cm.  in  breadth 
(Fig.  181).  Some  of  these  reach  7  mm.  in  thickness,  but  where  subjected  to 
pressure,  they  are  flattened.  The  small  tongue-like  masses  are  smooth  and 
glistening,  and  cannot  be  subdivided  into  smaller  ones,  as  is  usually  the  case  in 
adenocarcinoma  of  the  body.  After  hardening  in  Miiller's  fluid  it  is  jxjssible 
to  make  out  in  a  few  places  a  delicate  branching  or  tree-like  arrangement. 
The  larger  eminences  are  traversed  by  shallow  depressions,  which  to  a  slight  ex- 
tent subdivide  them  into  smaller  ones.  They  also  have  delicate  cajnllaries 
ramifying  over  them  in  all  directions.  Near  the  fundus  the  nuicosa  readies  2 
cm.  in  thickness,  and  only  its  superficial  portions  tend  to  become  polypoid. 
The  mucosa  in  its  (lee])er  j)oi'tioii  is  sharply  defined,  being  well  iiiarkeil  ni]'  from 
the  nuiscle,  which  it  a])])arently  has  not  penetrated.  The  jxisterioi-  wail  over 
a  limited  area  has  been  entii'ely  denuded  of  nmcosa  by  the  curet. 

Microscopically,  the  growth  proved  to  be  an  exceptionally  interesting  adeno- 
carcinoma. (The  histologic  findings  are  gi\-en  in  detail  in  Cullen's  "Cancer  of 
the  Uterus,"  p.  440.) 


288 


MVO.MATA    OF    THH    I'TKRUS. 


Gyn.  Nos.  1069  and  1782. 

r  t  ('  r  i  11  {'  111  y  0  111  a  I  a  :  c  a  r  c  i  11  o  in  a  o  f  t  h  c  h  o  d  y  o  f  the 
u  t  0  V  u  s  . 

L.  W.,  single,  white,  aged  forty-four.  Admitted  Xovciiihcr  Hi:  discharged 
Decenihcr  17,  ISOl.  The  iiKiistruatioii  has  hccii  profuse  for  the  last  three  or 
four  years;  lately  a.ss(jeiated  with  pain  in  the  lower  abdomen.  Operation,  No- 
vember 23,  1891,  removal  of  both  ovaries. 


Fig.  181. — Myomata  and  Adknocarci.noma  of  thk  Body  of  thk  Utkrus.  (f  nat.  size.) 
Gyn.  No.  4262.  Path.  No.  ll.'i?.  The  much  enlarged  uterus  has  been  opened  posteriorly.  Projecting  from 
the  posterior  surface  is  a  small  subperitoneal  myoma.  Scattered  throughout  the  walls,  which  are  increased  in 
thickness,  are  a  few  interstitial  myomata.  The  cervical  canal  is  imaltered.  The  uterine  cavity  is  much  eidarged. 
Projecting  into  it  from  the  anterior  wall  is  a  large  submucous  myoma.  Occupying  the  anterior  wall  and  extending 
over  the  posterior  wall  is  a  new-growth,  in  some  parts  forming  a  homogeneous  and  slightly  lobulated  mass,  but  in 
some  places  consisting  of  polypi  of  various  sizes  and  with  fairly  sharp  edges.  In  a  few  places  delicate,  finger-like 
outgrowths  spring  from  the  surface  of  the  polypi  or  from  the  depre.ssions  between  them.  The  new-growth  stands 
out  sharply  from  the  normal  mucosa  covering  the  pi)steri)r  wall,      (.\fter  Thomas  S.  Cullen.) 

She  was  again  admitted  on  January  29,  and  discharged  on  February  27, 
1893  (Gyn.  No.  17S2).  Operation,  February  1,  1S93,  hysteromyomectomy; 
amputation  through  the  eervix.  ( )n  removal  of  the  large,  irregular  myomatous 
uterus  carcinoma  of  the  body  was  found.  The  jjatieiit  made  a  ])erfect  recovery. 
\o  histologic  examination  was  made. 


Gyn.  No.  1691, 

A     s  1  o  u  g  li  i  n  g     s  u  b  m  u  c  o  u  s     m  y  o  m  a     associate  d     w  i  t  h 
carcinoma   of   the  body. 

Pi.  A.,  white,  sinuie.  aired   fol■t^■-(i^•e.     .\dniitte(l   Xovember  23:   discharged 


ADENOCARCIXOMA  OF  THE  BODY  OF  THE  UTERUS.  289 

December  29,  1892.  The  menses  were  regular  until  seven  years  ago,  after  whicli 
the  flow  appeared  every  two  weeks  and  was  very  })rofuse.  During  the  past  year 
it  has  been  almost  continuous.  The  bleeding  at  times  has  been  so  profuse  that 
the  patient  has  fainted. 

Operation,  November  28,  1892.  Hysteromyomectomy  with  amputation 
through  the  cervix.  When  the  uterus  was  opened,  a  sloughing  subnmcous  myo- 
ma was  found,  and  also  a  carcinoma  of  the  body.  A  note  was  made  on  August 
13,  1895,  that  the  patient  was  well  and  growing  fat;  her  only  complaint  was  of 
slight  backache.     No  histologic  examination  was  made. 

Gyn.  No.  9141.     Path.  No.  5312. 

A  large  cervical  m  y  o  m  a  ;  subperitoneal  and  intersti- 
tial uterine  m  y  o  m  a  t  a  ;  advanced  adenocarcinoma  of 
the   body  (Fig.  182). 

S.  T.,  single,  white,  aged  sixty-one.  Admitted  October  17,  1901.  The 
menopause  occurred  at  fifty-four.  For  the  past  six  years  there  has  been  a  slight 
yellowish  discharge,  and  five  years  ago  this  became  blood-tinged ;  for  the  ])ast  year 
it  has  been  offensive. 

Operation,  October  21,1901.  Panhysterectomy.  A  large  mass  above  the 
symphysis  was  found  to  be  the  fundus  ])ushed  up  from  below  by  a  myoma 
situated  near  the  cervix.  On  the  surface  of  the  uterus,  near  the  right  cornu, 
was  an  elevation,  2  cm.  in  diameter;  this  differed  entirely  from  an  ordinary 
myoma,  and  was  evidently  an  area  of  carcinoma  from  an  extension  of  the 
growth  through  the  uterine  wall.  Complete  hysterectomy  was  performed.  The 
patient  was  discharged  on  November  16,  1901. 

Path.  No.  5312.  The  specimen  consists  of  an  enlarged  uterus,  \\ith  its 
appendages  intact.  The  uterus  is  approximately  14  x  10  x  10  cm.  in  its  various 
diameters.  The  surface  is  smooth  and  glistening,  but  nodular.  Over  the  right 
cornu  is  an  irregular,  slightly  raised,  whitish  area,  with  puckered  margins.  Tt  is 
about  2  cm.  in  diameter,  and  closely  resembles  an  area  of  lupus  where  healing  has 
taken  place.  Scattered  throughout  the  uterine  walls  are  myomata,  the  chief  in- 
crease in  size  being  due  to  a  globular  myoma,  7  cm.  in  diameter  (Fig.  1S2).  This 
is  situated  directly  l)ehind  the  cervix,  and  has  evidently  ])r()jected  down  beneath 
the  peritoneum  into  Douglas'  cul-de-sac.  The  uterine  cavity  is  about  10  cm.  in 
length.  Th(>  nuicosa  of  the  cervix  presents  the  usual  apjx'arance,  but  the  cavity 
of  the  uterus  is  considerably  distended,  and  is  everywhere  lined  with  a  friable 
material  of  brain-like  consistence.  The  superficial  ])oitions  of  this  consist  of 
small,  delicate,  finger-like  ])r()jections,  and  c()\-ering  the  surface  is  neci-otic 
tissue.  The  growth  reaches  a  thickness  of  2  cm.  or  nioi-e,  and  is  everywhere 
penetrating  the  uterine  walls.  At  the  right  uteiine  horn,  where  the  puckering 
was  noticed  on  the  surface,  it  has  extended  to  the  peritoneum.  The  tubes  and 
ovaries  on  both  sides  are  apparently  normal. 

On  histologic  examination  the  growth  is  found  to  he  an  adenocarcinoma  with 
19 


290 


MYOMATA    OF   THK    UTERUS. 


a  (Icfiiiitf  tciulcncy  to  form  ])a{)illary  out  (growths.     Along  its  advancing  margin 
there  is  a  great  tlcal  of  round-celled  infilt I'ation. 


Fig.  182. — A  I.arck  Mvoma  ok  thk  Cehvix;  .\Di:xorARriN<)MA  of  the  Body  of  thk  I^teru!?.  (J  nat.  size.l 
Gyn.  No.  9141.  Path.  No.  5312.  Behind  the  cervix  is  a  globular  myomatous  nodule,  7  cm.  in  diameter. 
Smaller  subperitoneal  and  interstitial  myomata  are  also  seen.  The  uterine  cavity  is  filled  with  a  carcinomatous 
growth  which,  in  places,  reaches  2  cm.  in  thickness.  Over  the  right  uterine  horn  was  an  irregular,  slightly  raised, 
whitish  area,  with  puckered  margins,  and  closely  resembling  a  patch  of  lupus  where  healing  had  taken  place.  This 
represented  an  extension  of  the  carciiinnia  Id  the  peritoneal  surface  of  the  uterus  by  <'cintiiiuity. 


Gyn.  No.  9012.     Path.  No.  5180. 

M  y  o  m  a  tons  u  t  e  i'  u  s  :  a  d  e  n  o  c  a  r  c  i  n  o  m  a  of  t  li  v  body; 
d  o  II  b  1  e  h  \'  d  r  o  s  a  1  j)  i  n  x  ;  o  v  a  r  i  a  n  c  y  s  t  on  the  right  side; 
t  u  1)  o  -  o  V  a  r  i  a  n    abscess   o  11    the    1  e  ft    si  d  e  . 


ADEXOCAKCIXO.MA  OF  THE  BODY  OF  THK  UTERUS.  291 

M.  8.,  white,  aged  fifty,  iiiaiTicd.  Admitted  August  26;  discharged  Octo- 
ber 10,  1901.  During  the  last  eighteen  months  the  menses  have  been  irregular 
and  profuse;  Recently  there  has  been  bleeding  for  six  or  seven  weeks  at  a  time. 
During  this  ])eriod  the  patient  passed  a  hard  body,  probably  a  submucous 
myoma.  She  has  had  one  miscarriage.  Six  years  ago  she  was  told  that  her 
uteiiis  was  enlarged.  She  can  feel  something  shifting  about  in  the  al;)domen ;  this 
is  particularly  noticeable  when  she  moves  around. 

Operation.  Hysteromyomectomy;  radical  cure  of  hernia;  drainage  of  tubo- 
ovarian  abscess  through  the  abdomen. 

A  long  abdominal  incision  was  made,  and  a  small  umbilical  hernia  excised. 
Much  difficulty  was  experienced  on  account  of  a  tubo-ovarian  abscess  on  the  left 
side,  which  had  to  l:)e  drained.  The  left  tubo-ovarian  mass  was  very  closely 
associated  with  the  intestines,  and  the  omentum  was  thickened,  pale,  and  bled 
very  freely.  Resting  upon  the  ovarian  cyst  was  a  large  myomatous  uterus. 
Later,  the  perineum  was  repaired,  and  the  patient  left  the  hospital  very  much 
improved. 

Path.  No.  5180.  The  specimen  comprises  an  enlarged  uterus,  a  cyst  of  the 
ovary,  and  a  portion  of  a  small  ovarian  abscess.  The  uterus,  which  is  irregular 
and  pear-shaped,  measures  16  x  10  x  11  cm.  Its  surface  presents  irregular  prom- 
inences, corresponding  to  interstitial  myomata.  On  section,  a  large,  partially 
subperitoneal  myoma,  9  cm.  in  diameter,  is  found  occupying  the  fundus,  and  to 
one  side  of  this  is  an  interstitial  nodule  6  cm.  in  diameter.  This,  on  section,  ap- 
pears to  be  cystic,  consisting  of  fibrillated  material  with  translucent  areas  in  its 
meshes.  The  uterine  cavity  is  5  x  5.4  x  3.5  cm.  The  lower  portion  is  lined  with 
a  slightly  injected,  fairly  normal  looking  mucosa.  The  upper  portion,  however, 
is  occupied  by  an  exceedingly  friable  pajiillary  growth,  the  papillip  of  which  are 
long  and  finger-like.  The  advancing  margin  of  the  growth  is  fairly  well  defined; 
it  shows  a  rounded  but  somewhat  irregular  outline. 

The  right  ovary  has  been  converted  into  a  thin-walled  cyst,  18  x  15  x  15  cm., 
covered  with  numerous  tags  of  adhesions.  It  is  pale  nnldish  in  color,  and  by 
transmitted  light  is  found  to  be  unilocular;  it  contains  a  pale  yellowish  fluid.  .\n 
ovarian  al)scess  is  present  on  the  left  side. 

Sections  from  the  body  of  the  uterus  show  that  the  growth  is  an  adenocarcin- 
oma of  the  fundus. 

Gyn,  No.  10085.     Path.  No.  6275. 

S  u  I)  ])  e  r  i  t  0  n  e  a  I  ,  interstitial,  a  n  d  s  u  I)  m  u  c  o  u  s  ni  y  o  - 
m  a  t  a  ;  a  d  v  a  n  c  e  d  a  d  e  n  o  c  a  i"  c  i  n  o  ni  a  ,  i  n  \'  o  1  \"  i  n  g  b  o  t  h 
the   body   and   the   c  e  i' v  i  x    (l*'ig.  18;^). 

P.  I).,  white,  single,  aged  fifty-two.  Admitted  No\-einber  bS;  discharg(>(l 
December  17,  1902.  The  ])atient  first  noticed,  about  two  yeai's  ago.  that  her 
periods,  instead  of  gradually  sto))ping,  were  so  fi('(|uent  that  she  could  not  tell 
whether  she  was  having  a  contiinious  flow  or  when  the  next  ])eiiod  began. 
Hemoglobin,  55  per  c(>nt. 


292 


MYOMATA    OF   THE    I'TERUS. 


Operation,  hysterectomy.  The  lower  abdonieii  is  distended  with  a  nmlti- 
nodular  hard  mass  which  reaches  one-third  of  the  distance  from  tlie  symphysis 
to  the  umbihcus;  it  is  somewhat  movable. 

November  17,  1902:    .\n  incision  exposed  what  was  a])parently  a  myoma. 


Fig.  183. — SuBi'Kr.iToNKAi.,  IxTKRsTniAL,  and  SrnMrrous   Myomata;  Advanced  Adenocarcinoma  Involving 

Cervix  and  Body.     ((;  nat.  size.) 

Oyn.  No.  10085.  Path.  No.  6275.  The  uterus  is  much  enlarged,  measuring  15  cm.  in  length,  12  em.  in  breadth 
and  11  cm.  in  its  anteroposterior  diameter.  Scattered  throughout  it  are  numerous  myomata,  subperitoneal, 
interstitial,  and  submucous  (M).  The  cervix  is  intact,  as  seen  at  c,  where  there  is  a  cystic  gland.  The  entire 
uterine  cavity  is  lined  with  a  carcinomatous  growth.  The  tree-like  projections  are  in  evidence  near  the  cervi.x,  but 
in  the  ujjper  part  of  the  cavity  the  growth  is  more  pol.vpoid  in  form.  At  6  is  a  delicate  stem  of  the  growth  several 
centimeters  in  length,  and  terminating  in  a  club-like  e.xtremity.     a  indicates  the  normal  musculature  of  the  uterus. 

Simple  bimanual  examinaticm  in  this  case  was  strongly  stiggestive  of  a  normal  myomatous  uterus.  Had 
carcinoma  been  susi)ected,  under  no  <'ircumstances  would  bisection  have  been  commenced. 


Bisection  was  bci^un.  After  the  first  cut  there  was  a  p;iisli  of  a])pareiitly  car- 
cinomatous material  from  the  anterior  wall  of  the  uterus.  The  uterus  was  re- 
moved in  its  entirety  at  once.  The  patient  made  an  uneventful  recovery  and 
was  discharged  on  the  thirty-second  day. 


ADENOCARCINOMA  OF  THE  BODY  OF  THE  UTERUS.  293 

Path.  No.  6275.  The  specimen  consists  of  the  uterus  and  normal  appendages. 
The  uterus  is  globular,  about  15  x  12  x  11  cm.  Anteriorly  and  posteriorly  it  is 
smooth.  On  the  anterior  surface  is  a  smooth  myoma,  1.5  cm.  in  diameter. 
On  the  posterior  surface  several  smaller  ones  are  seen.  The  vaginal  portion  of 
the  cervix  looks  normal.  On  section,  it  is  found  that  portions  of  the  cervix  and 
body  have  been  replaced  by  a  new-growth  (Fig.  183).  The  cavity  of  the  uterus 
is  12  cm.  in  length.  The  growth  presents  a  very  shaggy  appearance,  and  consists 
of  many  tree-like  processes,  little  buds,  or  of  small  papillary  projections.  The 
individual  projections  vary  from  1  to  8  mm.  in  diameter.  The  growth  projects 
into  the  cavity  for  from  2  to  5  cm.  The  uterine  walls  are  only  slightly  en- 
croached upon.  Projecting  a  little  way  into  the  cavity  from  the  posterior  wall 
is  a  submucous  myoma  fully  3  cm.  in  diameter.  Numerous  other  myomata 
are  scattered  throughout  the  uterine  walls,  which  are  considerably  thickened. 

Histologic  examination  shows  that  the  growth  is  essentially  of  a  glandular 
character,  and  that  it  is  an  adenocarcinoma. 

The  general  contour  of  the  growth  strongly  suggests  myoma.  This  view  is 
supported  by  the  fact  that  there  are  somewhat  isolated  myomatous  nodules,  and 
one  might  very  readily,  as  was  done  here,  make  a  diagnosis  of  myoma.  Even 
with  the  abdomen  open  the  operator  felt  sure  that  he  was  dealing  with  a  myo- 
matous uterus.  Examination  of  scrapings  in  this  case  would,  however,  render 
the  diagnosis  easy. 

Gyn.  No,  9934.     Path.  No.  6127. 

Uterine    myomata;    a  d  e  n  o  c  a  r  c  i  n  o  m  a  o  f  t  h  e    body. 

J.  S.  B.,  white,  aged  fifty,  married.  Admitted  September  29;  discharged 
November  1,  1902.  One  aunt  died  of  a  uterine  tumor,  aged  fifty-five.  There  is 
tuberculosis  on  the  paternal  side.  The  patient  has  been  married  twenty-eigiit 
years,  but  has  never  been  pregnant.  During  the  past  two  years  the  nuMistrual 
flow  has  gradually  increased;  it  has  been  very  copious  and  frecjuent  for  the  last 
six  weeks,  and  the  patient  has  had  severe  hemorrhages.  Apart  from  a  pro- 
gressive weakness  due  to  loss  of  blood,  her  health  has  been  normal.  Hemo- 
globin, 55  per  cent. 

Operation.  Hysteromyomectomy  with  am])uta(i()ii  through  the  cci-vix.  The 
patient  was  discharged  November  1,  1902. 

Path.  No.  6127.  The  specimen  consists  of  an  enlarged  uterus,  amputated 
through  the  cervix.  The  ap])endages  arc  intact.  Extending  from  the  posterior 
wall  close  to  the  cervix  is  a  subperitoneal  myoma,  7  cm.  in  diameter.  On  section, 
it  shows  a  typical  hyaline  change.  The  body  of  the  uterus  is  considerably  en- 
larged, and  on  section  is  found  to  be  occupied  by  a  moderately  lai-ge,  caulillower- 
like  growth  which  extends  into  the  cavity  and  involves  the  uterine  wall  for  about 
one-half  its  thickness.  The  endometrium  lining  the  lowei-  portion  of  th(>  utin'ine 
cavity  is  quite  smooth. 

The  growth  on  histologic  examination  proves  to  be  a  typical  adenoeareinonia. 


204  MYO.MATA    OF    THK    I'TERUS. 


An  Exceptionally  Early  Adenocarcinoma  of  the  Body  of  the  Uterus,  Associ- 
ated WITH  A  Large  Myomatous  Uterus. 

The  foUowinii;  ease  is  only  one  exain])le  of  the  inten'sting  conditions  that  may 
he  (Ictcctcd  by  a  cai'cful  and  routine  examination  of  all  s])eeimens  coming  from 
the  operating-room.  The  multinodular  myomatous  uterus  measured  25  cm.  in 
diameter. 

0]i  histologic  examination  we  detected  one  of  the  earliest  carcinomata  of  the 
body  of  the  uterus  on  record  (Fig.  184).  The  growth  could  not  ])ossibly  be  seen 
macroscopically  on  account  of  its  small  size,  and  because  it  was  flush  with  the 
surface  of  the  nuicosa,  not  jirojecting  from  the  surface.  It  had  not  yet  penetrated 
the  muscle,  and  was  surrounded  on  all  sides  by  normal  mucosa.  The  general 
pattern  of  the  glands  left  absolutely  no  doubt  that  we  were  dealing  with  a  com- 
mencing carcinoma  of  the  body. 

Gyn.  No.  31 13.     Path.  No.  487. 

A.  y.  G.,  white,  aged  fifty-two.  Admitted  October  16;  discharged  De- 
cember 6,  1894.  The  other  interesting  features  in  this  case  are  reported  in  the 
chapter  on  Sarcoma  (p.  247). 

Path.  No.  487.  The  spt^imen  consists  of  a  large  globular  tumor  involving 
the  ui)per  portion  of  the  uterus.  It  is  approximately  circular,  and  has  a  diameter 
of  25  cm.  The  uterine  cavity  itself  is  6  cm.  long,  and  about  1  cm.  in  diameter. 
The  mucosa  is  yellowish  in  color,  and  at  the  cervix  is  somewhat  hemorrhagic. 
It  is  1  mm.  in  thickness. 

Histologic  Examination. — Some  of  the  cervical  glands  are  dilated.  The 
uterine  mucosa  in  most  places  is  atrophic.  The  surface  epithelium  is  intact,  the 
glands  are  few  in  number,  dilated,  small,  and  circular  on  cross-section;  some  of 
them  run  ])arallel  to  the  surface.  The  surface  of  the  mucosa  shows  considerable 
i"()un(l-celled  infiltration,  and  non-stripetl  muscle-filiers  are  seen  ])assing  up  into 
the  nnicosa  nearly  as  far  as  the  uterine  cavity.  Springing  from  the  mucosa  are 
three  polypi,  one  situated  near  the  internal  os,  and  having  a  broad  base,  a  second 
1.5  cm.  from  the  fundus,  presenting  a  pedunculated  appearance,  a  third  situated 
at  the  fundus.  These  polypi  are  covered  with  cylindric  epithelium  and  have 
numerous  glands  scattered  thi'oughout  them.  A  section  taken  at  one  point  in  the 
region  of  the  ])()lypi  gave  the  picture  seen  in  Fig.  184.  Here  we  have  normal 
mucosa  on  l)oth  sides,  and  over  a  very  small  area.  i)robably  not  more  than  1  to  2 
mm.  in  diameter,  the  glands  ai'e  so  changed  that  they  leave  no  doubt  as  to  the 
malignancy  of  the  growth.  The  surface  epithelium  is  becoming  thicker;  the 
cells  stain  more  palely.  The  epithelium  is  several  layers  in  thickness,  and  the 
glands  present  the  typical  ))icture  of  a  mucosa  undergoing  a  carcinomatous 
change. 

It  is  particularly  interesting  in  this  case  to  note  that  there  were  also  very 
suspicious  changes  in  the  cells  of  the  myomata.     The  muscle-fibers  contained 


ADENOCARCINOMA  OF  THK  BODY  O?^  THE  UTERUS. 


295 


large  oval  and  round,  vesicular  nuclei  (Fig.  102,  j),  248),  suggestive  in  a  slight 
degree  of  a  sarcomatous  transformation  of  the  myoma. 


Fio.  184. — Ax  Adknocarcinoma  of  the  Body  of  the  Uterus,  so  Small  that  it  could  not  be  Recognized 
EXCEPT  WITH  THE  Aid  OF  THE  Microscope.  (X  145diam.) 
Gyn.  No.  .3113.  Path.  No.  487.  This  picture  was  accidentally  discovered  during  our  routine  examination  of 
the  mucosa.  The  mucosa  to  the  left  and  right  of  the  field  is  normal.  The  surface  epithelium  between  «  and  a' 
and  between  6  and  b'  is  also  normal,  but  between  a'  and  6'  it  is  several  layers  in  thickness  and  stains  more  faintly. 
The  general  gland  pattern  in  the  central  area,  extending  from  c  to  c',  is  totally  different  from  that  of  the  normal  and 
surrounding  glands,  and  the  epithelium  has  proliferated  to  a  marked  degree.  The  epithelium  at  a'  also  shows  signs 
of  proliferation  and  sends  out  a  small  bud.  d  is  the  normal  uterine  muscle.  This  is  the  earliest  carcinoma  of  the 
body  of  the  uterus  we  have  ever  seen,  or  of  which  we  can  find  any  record  in  the  literature. 


Secondary  Carcinoma  of  the  Uterus,  Associated  with  Uterine  Myomata. 

Two  cases  of  this  character  haN'e  come  undei-  oui'  ol)S('r\ali(»n,  and  in  hoth 
instances  the  i^rimarv  carcinoma  was  of  ()\-ai'ian  origin. 

In  Case  7992  hotli  oN'ai'ies  were  carcinomatous  and  mdastases  were  I'ound  in 
the  Fallopian  tubes  and  uterus.  'V\\v  utci-us  contaiiuMl  two  small  sul))>('iiloncal 
and  several  small  interstitial  myomata. 

In  Cas(^  5528,  five  months  al'tci'  removal  of  both  oNai'ics,  on  account  of  a 
carcinoma,  a  com])lete  hysterectomy  became  ncccssarw  Flic  uterus  was  1 1  .\  12 
X  8  cm.,  and  contained  myomatous  nodules,  ^•al■ying  from  1  to  ()  cm.  in  diameter. 
Attached  to  the  right  side  of  the  uterus  was  a  ragged,  fi'iable  carcinomatous  mass, 


296  MYOMATA    OF    THE    UTERUS. 

8  cm.  ill  (liaiiieter.  Occupying  the  anterior  uterine  wall  was  a  carcinomatous 
mass  2x4  cm.  This  was  directly  continuous  with  the  uterine  mucosa  and  was 
soft  and  slightly  friable.  The  mucosa  itself  was  perfectly  smooth.  It  is  evident 
that  in  this  case  the  carcinomatous  nature  of  the  ovarian  growth  was  not  clear, 
otherwise  the  uterus  would  haN'e  b(>en  removed  with  the  ovarian  growths  at  the 
first  operation. 


CHAPTER  X\U. 
THE  CONDITION  OF  THE  UTERINE  MUCOSA  IN  CASES  OF  MYOMA. 

In  most  of  our  cases  when  the  uterus  has  been  removed,  supravaginal  am- 
putation has  been  employed.  As  a  result,  only  rarely  have  we  been  able  to  as- 
certain the  histologic  appearances  of  the  vaginal  portion  of  the  cervix. 

In  nearly  all  the  cases  in  which  the  uterus  was  removed  we  carefully  opened 
the  uterine  cavity  and  studied  the  appearances  macroscopically  and  histologically. 
Pieces  of  mucosa  were  removed  from  various  portions  of  the  cavity,  especial 
attention  being  given  to  any  area  suggesting  the  least  pathologic  change.  It 
will  readily  be  understood  that  a  histologic  examination  of  the  mucosa  from  all 
parts  of  the  cavity  in  over  1000  cases  would  be  out  of  the  question,  and,  therefore, 
the  pathologic  changes  in  a  few  cases  have  undoubtedly  been  overlooked.  The 
findings,  on  the  whole,  however,  are  relatively  accurate. 

The  mucosa  of  the  uterus  is  naturally  divided  into  two  main  kinds — that 
from  the  cervix  and  that  lining  the  uterine  cavity.  They  will,  therefore,  be 
considered  separately. 


CHANGES  IN  THE  CERVICAL  MUCOSA. 

Edema. 

Hypertrophy. 

Atrophy. 

Dilatation  of  the  cervical  glands. 

Cervical  polypi. 

Unfolding  of  the  cervical  glands. 

Cervical  endometritis. 

Suspicious  changes  in  the  cervical  mucosa. 

Carcinoma  of  the  cervix. 

Edema. — In  only  one  case  was  edema  of  the  mucosa  noted,  llci'c  the  uterus 
had  been  partially  inverted  by  a  submucous  iiiyoiiia. 

Hypertrophy. — Marked  increase  in  size  of  the  cervix  was  noted  four  times, 
and  on  i-cfcrring  to  p.  441  it  will  be  seen  that  in  each  of  these  cases  there  was 
])rolapse  of  the  uterus.  The  nuicosa  usually  showed  marked  thickening  of  the 
S((uanious  epithelium  of  the  vaginal  portion  of  the  cerxix.  and  the  papilhe  ])ro- 
j(>cting  into  the  s([uamous  (>pitheliuin  were  much  longer  than  usual  and  showed 
marked  branching. 

Atrophy. — Where  j)artiall>'  submucous  ceiAieal  niNoniata  exist,  the  cervix 
is  occasionally  so  unfolde(|  that  little  of  it  I'emains.     The  eei-xieal  nuicosa  is  put 

297 


298 


MVOMATA    OF    THK    UTKUrS. 


oil  marked  tension  and,  on  account  of  the  stn^tching,  ])ecoines  much  thinner  than 
usuaL  The  atropliy  is  iiioi-e  ai)i)arent  than  real,  the  appearance  being  duo  to  a 
thiiiniiiij:  out  of  the  mucosa,  which  now  has  to  cover  a  wider  area. 

Dilatation  of  the  Cervical  Glands. — Enlarged  glands  arc  very  coinmon  in  the 
cervix,  and  are  often  recognized  as  slightly  raised,  circular,  translucent  areas. 
In  our  experience  dilated  glands  are  not  more  freiiiieiit  in  myoma  cases  than  in 
those  in  which  no  tumor  exists. 

In  Case  3349  some  of  the  cervical  glands  reached  5  mm.  in  diameter. 

In  Case  3038  thev  reached  (i  mm.  in  diameter,  and  in  Case  3493  there  was  a 


V^/^   ^''f 


^  /  ^T  'V"!  '^^  r 


Fio.  185. — Markkd  Dilatation  ok  thk  Ckrvical  Glands,  with  a  Tendkncy  Toward  thk  Formation  of  a 

Polyp.     (X  5  diam.) 
Gyn.  No.  .349.3.     Path.  No.  715.     The  myomatous  uterus  was  16  x  16  x  22  em.     The  section  is  from  the  cervix. 
On  the  right,  at  a,  the  glands  are  normal,  and  on  the  left,  at  b,  the  mucosa  is  of  the  usual  thickness,  but  between 
these  two  points  the  glands  are  markedly  dilated,  some  being  spheric,  others  oblong  and  very  irregular.     The 
gland  epithelium  is  in  places  normal,  at  other  points  slightly  flattened. 


marked  tendency  toward  dilatation  of  the  glands  (Fig.  185).  One  gland  reached 
0.5  X  1.5  cm. 

41ie  dilated  glands  ai'e  usually  spheric,  hut  ma>'  he  ii'reguiar.  'Hie  gland 
contents,  as  a  rule,  are  viscid  and  semitranslucent;  occasionally  they  are  whitish 
yellow  or  opacjue,  owing  to  an  abundance  of  exfoliated  epithelium.  Their 
epithelium  may  be  high  eylindric,  or  considerably  flattened. 

Cervical  Polypi. — Polypi  of  the  cervical  mucosa,  in  our  ex])ericnec,  have  been 
comparatively  rare  in  myoma  cases.  In  some  cases  they  were  found  near  the 
internal  os;   in  others  they  were  near  the  external  os,  or  projected  slightly  into 


THE    COXDITIOX    OF    THE    CERVICAL    MUCOSA    IX    CASES    OF    MYOMA.  299 

the  vagina.     They  wort'  u.>^ually  single,  Init  occasionally  several  were  present,  as 
in  C.  H.  I.  Xo.  768. 


..-'VJ^JtJ^^tS 


Fig.    186. — A  Ckrvical   Polyp.      (X  8   diam.) 

Gyn.  No  6169.  Path.  No.  2426.  The  uterus  contained  a  small  submucous  myoma.  The  endometrium  pre- 
sented a  wavy,  polypoid  appearance,  and  polypi  were  found  in  the  cervix. 

At  a  and  a'  we  have  a  normal  mucosa.  Projecting  from  the  mucosa  is  a  polyp  attached  by  a  broad  base, 
the  confines  of  which  are  indicated  by  6  and  b'.  The  polyp  consists  of  normal  cervical  mucosa.  A  dilated  gland 
is  seen  at  c.     rf  is  a  very  small  polyp.     At  e,  a  dilated  gland  is  seen  deep  in  the  stroma  of  the  cer\'ix. 


The  size  of  the  uterus  or  the  situation  of  the  myomata  seemed  to  have  little 
or  no  influence  on  the  development  of  the  polypi,  as  they  occurred  just  as  fre- 
quently when  the  myomata  were  small  and  when  no  submucous  nodules  existed. 


^'^^.■- 


.liA 


-r't^^^V-;       /^b 


cj  /'•^■i  .,^>s-r\^ 


Fig.  187. — A  Ckhvuai,  Poi.vp.     (X  6  diam.) 

Gyn.  No.  6169.  Path.  No.  2426.  The  uterus  contained  a  small  .submucous  myoma.  Tho  cervix  C(»ntaiiied 
the  polyp  (le|)ict{'d  in  Fig.  186. 

This  polyp  is  made  up  chiefly  of  long,  finger-hke  outgrowths  of  cervical  mucosa.  The  struma  reseml>les  tliat 
of  a  normal  cervix,  and  the  projections  are  covered  with  the  chararlcrislic  liigh  cyhndric  epithelium  of  the  cervix. 
The  iJolyp  was  attached  to  the  cervical  mucosa  by  a  delicate  i)edicle,  indicated  on  the  left. 


On  histologic  examination  some  of  the  i»oly)ii  closely  reseiiiMed  the  noniial 
cervical  mucosa  (Fig.  ISfi)  and  wci-e  in  realit\-  nothing  more  than   small   areas 


300  MYOMATA    OF   THE    UTERUS. 

of  iiiueou.s  iiienibranc  that  had  been  extruded  and  partiahy  nipped  off.  In  other 
polypi  the  process  of  extrusion  had  advanced  further.  The  polypi  were  com- 
))()sed  of  long  narrow  tongues  of  mucosa  (Fig.  187),  and  the  attachment  to  the 
j)arent  nmcosa  was  very  slender. 

In  San.  No.  1872  (Path.  No.  8433)  the  glands  of  the  polypi  were  uniformly 
and  markedly  dilated,  and  the  picture  resembled  closely  that  of  a  thyroid  gland. 

A  II  a  !•  e  1'  ()  r  m  of  Cervical  Polyp  . — In  the  following  case,  in  which 
a  small  submucous  myoma  was  removed,  a  large  cervical  polyp  was  also  taken 


■'•.  0  , 


ti?"' 


-<r   - 


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c 

jft  ■  *^-»^-j* 

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i.f^ -^   ^         ^ 

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■%/  '  .  -^  J'i'K 


M-  K^' 


Fig.  188. — A  Rare  Form  of  Cervical  Poi.yp.     (X  Otliani.) 
Gyn.  No.  7615.     Path.  No.  3879.     This  is  a  small  portion  of  a  cervical  polyp,  1.5  x  3.5  x  4.5  cm.     The  polyp 

was  mottled  in  appearance  and  contained  cyst-like  spaces,  some  minute,  others  reaching  3  mm.  in  size.    The  glands 

are  indicated  by  a.     Some  are  of  the  normal  size,  others  much  tlilated  and  spheric. 

Scattered  throughout  the  polyp   are  many  pale-staining  anil  solid  areas  (6),  which,  under  the  lower  power 

bore  some  resemblance  to  cartilage.     For  the  finer  details  of  the.se  areas  see  Fig.  1S9,  in  which  the  area  indicated 

by  c  is  magnified. 

away.     The  histologic  api)earances  of   the  polyp  are  .so  unusual  that  we  give 
them  in  detail. 

Gyn.  No.  7615.  Path.  No.  3879.  The  i)atieiit  was  fifty-one  years  of  age,  and 
the  operation  consisted  in  the  removal  of  two  polypoid  masses  from  the  cavity 
of  the  uterus.  The  specimen  com])rises  two  small  tumor  masses.  The  larger 
of  these  is  4.5  x  3.5  x  1 .5  cm.,  {)resents  a  lobulated  apjiearaiice,  and  has  a  mottled 
surface,  with  areas  of  dark  green,  gray,  or  bright  red.  On  section,  it  is  found  to 
contain  cyst-like  spaces,  varying  from  a  pinj)oint  to  2  or  3  mm.  in  diameter. 


THE    CONDITION    OF   THE    CERVICAL    MUCOSA    IN    CASES    OF   MYOMA.  301 

This  growth  is  a  polyp.     The  small  tumor  measures  1.5  x  2.5  cm.,  and  consists  of 
myomatous  tissue. 

Sections  from  the  large  and  cystic  polyp  show  that  the  surface  is  devoid  of 
epithelium,  and  that,  to  a  great  extent,  the  superficial  portion  consists  of  granu- 
lation tissue  on  the  surface  of  which  is  fibrin  containing  polymorphonuclear 
leukocytes  in  its  meshes.  The  tissue  immediately  beneath  the  granulation  zone 
shows  much  small-round-celled  infiltration.  The  stroma  of  the  polyp  resembles 
that  ordinarily  found  in  the  cervical  mucosa,  and  penetrating  it  in  all  directions 
jire  cervical  glands.  These  are  more  convoluted  than  usual,  and  contain  many 
delicate,  teat-like  ingrowths.  The  epithelium  lining  most  of  these  glands  still 
preserves  its  normal  type,  and  in  some  places  the  cells  are  flattened  and  the 
nuclei  stain  deeply.     Occasionally  there  is  proliferation  of  the  gland  epithelium. 


*-.  f^.//?'^i--- 


^^^^^^^4^*cVr^^ 


Fig.  189. — A  Rare  Form  ok  Cervical  Polyp.     (X   120di:iin.,) 
Gyn.  No.  7615.     Path.  No.  3879.     The  picture  represents  an  enlargement  of  the  area  c  in  Fig.  18S.     The 
stroma  of  the  polyp  consists  of  ordinary  cervical  stroma,  but  scattered  throughout  it  is  much  blood.      The  cells  of 
the  pale-staining  area,  the  confines  of  which  are  indicated  by  a  and  6,  consist  of  polygonal  cells  having  round  or 
oval  nuclei.     The  protoplasm  of  these  cells  took  the  hematoxylin  stain  faintly. 

several  layers  of  cells  being  present.  Some  of  the  glands  are  much  (lilat(Hl.  jii'o- 
ducing  the  cysts  noted  macro.scopically.  The  ei)ithelium  of  the  dilated  glands 
is  much  flatten(>d,  and  at  some  jjoints  has  disa})j)eare(l.  Scattered  throughdut 
the  stroma  are  large  oval  or  ii'regulai',  deeply  staining  areas,  under  the  low  power 
strongly  suggesting  cartilage  (Fig.  188),  but  when  examined  with  the  high  power, 
differing  much  therefrom  (Fig.  189).  The  individual  cells  of  these  areas  are 
polygonal  in  shape,  ha\-e  o\'a]  or  roiiiid.  unifoniily  staining  nuclei,  and  a  ])ro- 
toplasm  that  takes  the  hematoxylin  stain  faintly.  These  areas  were  at  first 
sight  thought  to  I'ejiresent  broken-down  cervical  glands,  but  on  closei-  examina- 
tion they  resemble  more  a  mucoid  t ransfonnation  of  the  stroma,  although  it  is 
difficult  to  explain  the  sharj)  line  of  demarcation  between  them  and  the  stroma. 
We  have  never  seen  another  ))oly))  jirescMiting  these  ]i(>culiarities. 


302  MYO.MATA    OF    THE    UTERUS. 

Unfolding  of  the  Cervical  Glands. — In  those  cases  in  which  the  cervical  canal 
is  much  drawn  out  or  the  mucosa  of  the  cervix  is  put  on  great  tension  by  a  large 
submucous  myoma,  the  glands  may  literally  unfold.  The  gland  epithelium  then 
forms  part  of  the  lining  of  the  cervical  canal.  Although  the  scjuamous  epithelium 
usually  ends  at  or  ik  :w  the  external  os,  it  may  extend  far  up  into  the  canal.  If 
such  is  the  case,  when  the  unfolding  of  the  glands  takes  place,  the  epithelial 
hning  will  consist  of  two  ty])es — squamous  e])ithelium,  alternating  with  the  high 
cvlindric  varietv.     Such  a  con(Hti()n  we  have  noted  on  several  occasions. 

Cervical  Endometritis. — InHannnation  of  the  cervical  mucosa  is  relatively 
freiiuent  when  a  sloughing  submucous  myoma  or  a  carcinoma  of  the  uterus 
exists,  but  is  rarely  found  under  other  circumstances,  even  if  there  be  an  old 
inflammatory  process  in  the  adnexa. 

Tn  Case  3199,  in  which  the  cervical  glands  showed  ])rolif(>ration,  there  was  a 
marked  small-round-celled  infiltration,  but  the  surface  ejnthelium  was  intact. 

In  Case  12221  there  was  likewise  new  gland-formation  in  the  cervix.  In 
places  the  surface  epithelium  was  intact,  but  at  other  jjoints  it  had  l)e(>n  rejilaced 
by  granulation  tissue. 

In  Case  2800  (Path.  No.  312)  the  omentum  was  adherent  to  the  large  multi- 
nodular uterus  over  a  wide  area,  and  the  ai)pendages  were  bound  u\)  in  adhesions. 
The  cervical  mucosa  presented  a  branching,  arl)orescent  ai)pearance.  The 
sm-face  epithelium  was  intact,  and  covered  with  polymorphonuclear  leukocytes, 
while  the  underlying  stroma  showed  marked  small-round-celled  and  polymor- 
phonuclear infiltration. 

In  Case  12139  the  woman  had  been  in  the  hospital  seven  years  before,  a 
pelvic  abscess  being  evacuated  through  the  vagina  at  that  time.  When  the 
abdomen  was  ojjcned,  the  omentum  was  found  glued  to  the  myomatous  uterus, 
and  general  ])elvic  adhesions  were  encountered.  Sections  from  the  cervix  showed 
that  the  .surface  was  covered  with  ])olymorphonuclear  leukocytes.  The  surface 
e])ithelium  was  intact,  but  the  underlying  stroma  showed  much  small-round- 
celled  infiltration. 

Suspicious  Changes  in  the  Cervical  Mucosa. — In  at  least  five  of  our  mj'oma 
cases  sections  fioin  the  cervix  have  yielded  rather  .suspicious  histologic  pictures 
when  macroscoj)ically  nothing  abnoi-mal  could  be  detected. 

The  uterus  in  Case  341S  (Path.  Xo.  (ifil )  was  the  seat  of  a  diffuse  adeno- 
myoma  of  the  ])osterior  wall.  The  cervical  glands  wer(>  in  some  places  normal, 
but  here  and  there  had  ))rolif crated.  'Hie  epithelium  lining  the  cervical  canal 
was  intact. 

In  Case  3199  (Path.  No.  524)  the  nuiltinodular  myomatous  uterus  reached  to 
the  umbilicus.  The  cervical  epithelium  was  intact,  but  the  glands  were  smaller 
than  usual,  and  appeared  to  have  i)r()liferated.  The  newly  formed  glands  were 
small  and  had  a  lining  of  cuboid  epithelium.  They  did  not  ajipear  to  extend  far 
into  the  stroma,  but  the  latter  .showed  marked  infiltration,  with  small  round 
cells. 


THE    COXDITIOX    OF    THE    CERVICAL   MUCOSA    IX    CASES    OF    .MYOMA. 


303 


'^& 


In  Case  3349  (Path.  No.  ()10)  the  nodular  myomatous  uterus  measured  10  x 
12  X  16  cm.  Some  of  the  cervical  glands  were  dilated.  In  close  proximity  to 
one  of  the  glands  was  an  aggregation  of  minute  glands,  some  of  which  were 
branching.  They  were  lined  with  culwid  ciliated  epithelium,  and  had  round  or 
oval  nuclei  situated  near  the  center  of  the  cells.  The  picture  instantly  suggested 
commencing  adenocarcinoma. 

The  myomatous  uterus  in  Case  12221  (Path.  No.  8832)  measured  6  x  7  x  10 
cm.  The  cervical  glantls  had  proliferated,  forming  many  new  and  smaller  ones. 
The  cell  proliferation  had  in  places  ad- 
vanced so  far  that  solid  nests  had  been 
formed.  These  resembled  masses  of 
squamous  epithelium.  At  other  points  the 
surface  epithelium  had  been  replaced  by 
typical  granulation  tissue. 

In  one  of  our  cases  we  found  very  sus- 
picious changes  in  the  uterine  mucosa, 
changes  which  strongly  indicated  that  a 
malignant  growth  was  starting  in  the 
mucosa.  In  Case  3133  the  abdomen  was 
filled  with  a  myomatous  tumor,  36  x  32  x 
32  cm.  On  histologic  examination  some 
very  interesting  changes  were  found.  Fig. 
190  represents  a  portion  of  a  gland 
in  the  cervix.  The  epithelium  on  one 
side    is    normal;    on   the    other    side    the 

...  .  Gyn.   No.   .3133.     Path.  No.  494.     The  sec- 

nuclei  are  mcreasmg  m  size,  and  there  is  tion  shows  a  portion  of  a  gland;  a  and  a 
a  large  circular  nucleus  projecting  into  the 
lumen.  A  section  from  the  same  region 
shows  more  marked  changes  (Fig.  191). 
Here  and  there  through  the  surface  are 
large  masses  of  i)roto])lasm  which  ai'c 
totally  devoid  of  nuclei,  and  near  the  cen- 
ter of  the  field  is  a  nucleus  at  least  ten 
times  as  large  as  the  suiTounding  ones, 
staining  more  deei)ly,  and  showing  many  hyaline  dro})lets.  That  this  largi 
cell  is  distinctly  abnormal  is  cleai'ly  indicated  by  the  zone  of  small  round 
cells  which  partially  wall  it  off  fi'om  the  uterine  tissue.  ()thei-  sections  show 
that  the  surface  ej)ithelium  has  a  decided  tendency  to  torin  finger-like  out- 
growths (Fig.  192)  or  slender  pi-ojections  comjjosed  eiilii-ely  of  e))ilhehuiii. 
At  d  the  nucleus  of  the  epithelial  cell  is  becoming  larger  mid  slnins  more  deeply. 
The  entire  picture  stnjiigly  suggests  a  comiiieiiciiig  c;ii-ciiioMi;i  of  ihe  utems. 


Fig.  190. — Sispinous  Epithelial  Changes  ix  a 
Gland  from  the  Cervix,  Associated  with  a 
Large  Myomatous  Uterus.     (X  360diam.) 


dicate  opposite  walls;  h  and  c  represent  irregular 
nuclei,  lioth  of  which,  however,  are  of  normal 
size.  The  nuclei  d  and  e  are  much  enlarged, 
and  the  nucleus  /  even  more  so.  Normally,  nuclei 
of  such  a  size  anil  character  never  exist  in  the 
epithelium,  and  their  presence  strongly  .suggests 
a  malignant  tendency  in  the  uterine  mucosa. 
(For  other  changes  see  Figs.  191  and  192.)  .\t 
several  points  cilia  are  demonstrable;  they  are 
particularly  well  seen  at  Q.  The  luulerlying 
stroma  is  practicidly  normal,  hut  a  few  small 
round  cells  are  wandering  in  at  h. 


304 


MYOMATA    OF   THE    UTERUS, 


Gyn.  No.  3133.     Path.  No.  494. 

A  large  m  y  o  m  a  t  o  u  s  uterus,  ^^•  i  t  h  changes  in  the 
m  II  c  o  s  a   V  c  r  v   suggestive   of   a   commencing   c  a  r c  i  n  o  m  a  . 

M.  J].  K..  aged  fifty,  white,  married.  A(hnitted  October  24;  discharged 
Xovemhcr  24,  1S94.  A  supravaginal  hysterectomy  was  ])erformed.  Recovery 
was  uninterrujjted. 

Path.  No.  494.  The  specimen  consists  of  a  greatly  enlarged  uterus,  with 
the  tubes  and  ovaries  intact.  The  uterus  is  ])ear-sha])cd  and  measures  36  x  32 
X  32  cm.  Th(>  upper  surface  of  the  tumor  is  covered  with  j^eritoneum  and  is 
smooth  and  glistening.  The  lower  two-thirds,  both  anteriorly  and  posteriorly, 
are  denuded  of  peritoneum.  Projecting  through  the  cervical  canal  is  a  small 
uterine  jiolyi).     The  portion  of  the  uterine  cavity  present  is  31  cm.  long,  and 


Fig.  191. — Srspiciors  Epituki  ial  Changks  in  tiik,  Mlcosa  of  thk  Cervix,  kro.m  a  Larcf.  Myomatous  Uterls. 

(X  390  diam.) 

Gyn.  No.  .313.3.  Path.  No.  494.  a  represents  the  normal  thickness  of  the  surface  epitheHvun,  ami  b  shows  a 
nucleus  of  normal  size,  c,  d,  and  e  are  Rranular  masses  of  protoitlasiu  of  various  sizes.  They  resemble  miniature 
■■  ijuff  balls,"  and  are  devoid  of  nuclei. 

/  is  an  exceptionally  large  nucleus  containing  aggregations  of  chromatin  and  large  and  small  hyaline  droplets. 
This  nucleus  is  strongly  suggestive  of  an  early  malignant  change.  Nature  evidently  fears  trouble,  as  she  is  partially 
walling  it  off  with  many  small  round  cells  (a). 


varies  from  9  to  14  cm.  in  breadth.  I'he  mucosa  is  whitish  yellow  in  color, 
smooth  and  glistening,  and  apparently  ver}'  thin.  Sixteen  centimeters  from  the 
fundus  is  a  polyp  3.5  cm.  long,  1  cm.  broad  at  the  base,  and  2  mm.  in  thickness;  it 
is  attached  by  a  very  delicate  pedicl(\  In  the  posterior  wall,  about  12  cm. 
from  the  fundus,  is  a  yellowish  area,  3  cm.  in  diameter.  From  this  mucus  mixed 
with  l)lood  oozes  into  the  uterine  caNity.  The  cavity  from  which  the  mucus  can 
l)e  sf[ueezed  has  .smooth  walls. 

On  histologic  examination  the  entire  uterine  mucosa  is  markedly  ati"ophied, 
and  seems  to  consist  of  one  layer  of  epithelium,  resting  almost  directly  upon  the 
uterine  muscle.  The  surface  of  th(»  muco.sa  in  the  cervical  ])ortion  is  compara- 
tively smooth,  but  near  the  fundus  it   becomes  somewhat   convoluted.     The 


THE    CONDITIOX    OF   THE    UTERINE    MUCOSA    IX    CASES    OF   MYOMA.  305 

epithelium  lining  the  lower  part  of  the  uterus  is  alternating,  for  a  certain  area 
being  of  the  cervical  type,  then  of  the  body  type,  and  then  again  of  the  cervical. 
The  chief  interest  centers  in  the  suspicious  pictures  noted  in  Figs.  190,  191, 
and  192. 

It  will  be  noted  that  in  each  of  these  five  cases  the  picture  was  suggestive 


Fig.  192. — Suspicious  Proliferation  of  the  Cylindric  Surface  Epithelium  of  the  Cervix,  Associated 
WITH  A  Large  Myomatous  Uterus.  (X  lOOdiam.) 
Gyn.  No.  3133.  Path.  No.  494.  a  and  a'  indicate  normal  surface  epithelium,  .-it  b  the  epithelium  is  several 
layers  thick,  and  at  c  forms  distinct  outgrowths,  totally  devoid  of  a  supporting  stroma.  This  condition  in  itself  is 
strongly  suggestive  of  a  malignant  change.  At  d  is  an  enlarged  and  more  deeply  staining  nucleus.  Scattered 
among  the  epithelial  cells,  and  also  in  the  stroma,  are  small  round  cells  and  polymorphonuclear  leukocytes. 

of  a  beginning  carcinoma,  but  in  no  instance  was  the  evidence  conclusiv(\     In 
two  of  the  five  cases  an  inflammation  of  the  cervix  was  present. 

Carcinoma  of  the  Cervix. — From  p.  262  it  will  be  seen  that  in  eighteen  cases 
carcinoma  of  the  cervix  was  associated  with  uterine  myomata.  As  each  of  the 
cases  is  described  in  detail  in  another  portion  of  the  book,  further  reference  to 
them  here  is  unnecessary. 

THE  UTERINE  CAVITY  IN  MYOMA  CASES. 
Size  and  shape  of  the  uterine  cavity. 
Partial  obliteration  of  the  uterine  <'avity. 
Blood  in  the  uterine  cavity. 
Pus  in  the  uterine  cavity. 

Size  and  Shape  of  the  Uterine  Cavity  when  Myomata  are  Present. 

The  size  and  shape  of  the  uterine  cavity  dejM'iid  in  a  great  measure  on  the  size 
and  situation  of  the  uterine  tumors.  If  a  myoma  develops  in  the  u))]H'r  part  of 
the  fundus,  the  cavity  may  remain  normal  in  size  or  be  very  small  (Fig.  194). 
If  the  tumor  is  intraligamentary,  it  may  reach  veiy  large  proportions  without 
causing  the  cavity  to  increase  in  size.  On  the  other  hand,  when  a  myoma 
remains  interstitial  and  reaches  large  proportions,  with  tlie  graihial  enlargement 
of  the  tumor  there  is  a  corresponding  lengthening  and  often  broadening  of  the 
20 


306 


.MVOMATA    OF    THE    ITEHUS. 


Uterine  cavitw  The  caxity  may  retain  its  normal  shajx',  hut  if  invaded  l)v 
suhniucous  myomata,  it  heoomes  greatly  distorted  and  may  he  very  tortuous. 
In  Fig.  198  we  have  an  example  of  a  large  myomatous  uterus  with  a  tortuous 
hut  slit-like  cavity. 

The  following  cases  give  a  fail'  idea  of  the  various  shapes  and  siz(^s  that  the 
uterine  cavity  may  assume. 

In  Case  2919  (Path.  No.  8S())  the  multinodular  myomatous  uterus  measured 
11  X  18  X  14  cm.  The  myomata  were  interstitial  and  suhpei'itoneal.  The 
cavity  of  the  uterus  was  scarcely  more  than  1  cm.  in  length.  It  is  diHicult  to 
account  for  .such  a  small  cavity  in  a  patient  only  thirty-four  years  of  age.  The 
mucosa,  however,  was  fully  1  cm.  thick. 


Fig.  193. — .A.  .Siit-iikk  Torti  ors  rTKiiixi;  Cavity.     (J  nat.  size.) 

Path.  No.  2.53S.  Scattered  throughout  the  uterine  walls  are  many  interstitial  myomata,  and  projecting  from 
the  surface  are  several  others.  The  upper  part  of  the  cervix  is  readily  recognized  in  the  lower  i)art  of  tlie  picture. 
The  upper  part  of  the  uterine  cavity  appears  a.s  the  narrow  chink  a. 


In  Case  12086  (Path.  No.  8727)  the  myomatous  uterus  was  22  cm.  in  breadth 
and  12  cm.  in  its  anteroposterior  diameter.  The  uterine  cavity  formed  a  caver- 
nous space,  5  x  (>  cm.  Its  walls  could  not  dro])  together,  as  in  Fig.  198,  ])ecause 
the  uterine  cavity  was  literally  paved  with  ni\-omata,  whose  ])resence  rendered 
it  a  non-collapsible  space. 

The  uterus  in  Case  5784  (Path.  Xo.  2084)  was  much  enlarged,  being  converted 
into  a  lobulated  tumor  14  x  19  x  27  cm.  Thegretit  increase  in  size  was  due  chieHy 
to  the  presence  of  three  subperitoneal  myomata,  averaging  11  cm.  in  diameter. 
The  uterine  cavity  was  narrow  and  tortuous,  approximately  10  cm.  long,  and 
averaging  l.o  cm.  in  diameter. 


THE    COXDITIOX    OF    THE    UTERIXE    :\irCOSA    IX    CASES    OF   MYO.MA. 


]o: 


In  Case  3491  (Path.  No.  713)  tho  globular  uterus  inoasured  16  cm.  in  diameter. 
Occupying  the  posterior  wall,  and  projecting  into  the  cavity,  was  a  myoma  12 
cin.  in  diameter.  The  uterine  cavity  was  13  cm.  long  and  9  cm.  broad  in  its 
upper  portion. 

The  globular  uterus  in  Case  5617  (Path.  No.  1962)  was  22  cm.  in  diameter, 
and  reseml^led  a  pregnant  organ.  Situated  in  the  anterior  wall  was  a  myoma 
17  cm.  in  diameter.  The  uterine  cavity  was  22  cm.  in  length  and  13  cm.  broad 
at  the  fundus. 

One  of  the  largest  uterine  cavities  we  have  ever  seen  was  furnished  by  Case 
3133  (Path.  No.  494).     The  uterus  was  pear-shaped,  measuring  32  x  32  x  36  cm. 


Fii;.  194. — A  Very  Small  Uterink  Cavity  with  a  Large  Myoma  ok  the  Fundus,     (f  iiat.  size.') 

Gyn.  No.  1()9U).     Path.  No.  7162.     The  globular  myoma,  which  was   11  cm.  in  diameter,  ha.s  been  split   in  two 

The  uterine  cavity  was  not  over  2  cm.  in  length.     The  mucosa  presented  the  usual  appearance. 


The  great  increase  in  size  was  due  to  the  j)i'('sence  of  a  myoma  occupying  the 
anterior  wall.  The  uterine  cavity  was  31  cm.  long,  and  varied  from  9  to  14  cm. 
in  breadth.  Situated  in  the  posterior  wall,  about  12  cin.  from  the  fundus,  was  a 
yellowish-area,  3  cm.  in  diameter.  From  this  nmcus  mixed  with  blood  escaped 
into  the  uterine  cavity.  This  secondary  cavity,  on  histologic  examination,  was 
tound  to  ))e  lined  with  one  layer  of  e])il helium,  and  seemed  to  be  a  markedly 
dilated  gland. 

The  f(M"egoiiig  exam])les  are  sullieieiil  to  show  ihal  the  uleiiiie  caxity  may 
assume  almost  any  size  and  sha|)e,  and,  furthei',  that  the  alteralion  is  dependent 
entirely  on  the  size  and  position  of  the  niyomata. 


308 


MYOMATA    OF    THE    UTERUS. 


a< 


Kgtr-^VP 


c  -^-.. 


Partial  Obliteration  of  the  Uterine  Cavity. 
In  a  few  of  the  ctises  of  suhimicous  niyoniata  the  mucosa  from  the  anterior  wall 
isso firmly  jjressed  aiiaiiist  that  of  the  posterior  wall  that  the  walls  become  adherent 

and  the  mucosa  disappears  from  this  area. 
Thus  in  Case  300S  (Path.  No.  435),  in  which 
the  multinodular  myomatous  uterus  filled 
the  pelvis,  the  uterine  cavity,  which  was  6 
em.  in  length,  had  become  partially  obliter- 
ated by  a  submucous  nodule,  situated  in  the 
anterior  wall,  becoming  adherent  to  a  similar 
nodule  in  the  posterior  wall,  thus  giving  the 
cavity  an  X-shaped  contour.  The  uterine 
mucosa,  on  the  whole,  is  normal,  but  toward 
the  point  at  which  the  uterine  cavity  is  par- 
tially obliterated  the  mucosa  becomes  some- 
what atrophic,  and  that  of  the  anterior  fuses 
with  that  of  the  posterior  wall.  The  glands 
gradually  diminish  in  number,  and  then  en- 
tirely disappear,  leaving  only  a  small  amount 
of  stroma  (Fig.  195).  This  finally  disaj)- 
pears,  and  the  muscle  from  the  anterior  wall 
becomes  continuous  with  that  from  the  pos- 
terior wall.  At  the  point  of  junction  arc 
numerous  blood-vessels,  and  the  muscle 
shows  small-round-celled  infiltration.  On 
})assing  still  further  toward  the  upper  part 
of  the  cavity  the  mucosa  gradually  reap- 
pears, and  near  the  toj)  of  the  ca\'ity  has 
regained  its  normal  ai)])earance. 

In  Case  3111  (Path.  No.  479),  the  multi- 

the   anterior  wall,    becoming   adherent    to   a 

similar    nodule    in    the    posterior  wall,    thus  Uodular  myomatOUS  UtcrUS  WaS  9  X  10  X  9  Clll. 

giving  the  cavity  an  x-shaped  contour.  ^j^^.     ^,j^,,-j^,^     ^..^^,j^         ^^..^^     5     p„,       j,,      j^.j^^^^ 
Ihe  section   i.s   taken    from  the  point  of  '  <^ 

The  mucosa  covering  the  small  submucous 
myoma  in  the  anterior  wall  had  become  ad- 
herent to  the  corresponding  mucosa  of  the 
))osterioi-  wall,  thus  partially  ol)literating  the 
cavity.  On  histologic  examination  it  was 
found  that  where  the  nodule  projected  into 
the  uterine  cavity  the  mucosa  siuklenly  be- 
came compresscHJ  (Fig.  196),  that  from  the  anterior  wall  being  directly  con- 
tinuous with  that  from  the  posterior  wall.  The  mucosa  became  still  more 
atrophic,  and  o\<i-  the  most  prominent  part  of  the  nodule  entirely  disappeared. 


.r- 


1 


Fig.   195. — Partial    Obliteration    of    thk 
Uterine  Cavity  with  Disappearance 
OF  THE  Mucosa.     (X4diam.) 
Gyn.  No.  300S.     Path.  No.  4.35.     In  this 
case  the    uterine    cavity  was    partially  oblit- 
erated by    a    submucous   nodule,  situated  in 


coalescence.  Pres.-^iiig  in  from  either  side  are 
myomata,  the  edges  of  which  are  indicated 
by  m.  a,  is  the  normal  mucosa  from  the  up- 
per part  of  the  cavity.  At  c,  where  most 
pressure  ha-s  been  exerted,  all  trace  of  mucosa 
has  disappeared.  In  the  lower  part  of  the 
field,  as  indicated  by  b,  the  mucous  membrane 
is  again  present,  but  is  markedly  compressed. 
The  clear,  elongate,  and  irregular  si)aces  are 
blood-vessels. 


THE    CONDITION'    OF   THE    UTERINE    MUCOSA    IN    CASES    OF    MYOMA. 


309 


Here  the  muscle  from  the  posterior  wall  was  directly  continuous  with  that 
covering  the  submucous  myoma.  The  line  of  fusion  could  still  be  recognized 
by  a  moderate  infiltration  with  small  round  cells.* 


^.v^^ 


A   Ho  f, 


Fig.  196.— Partial  Obliteration  ok  the  Utiorink  Cavity  Calskd  h\   a  Suumucols  Myoma.    (X   6  diam.) 

Gyn.  No.  3111.  Path.  No.  479.  The  uterus  mea.sured  9x10x9  cm.,  and  contained  interstitial  and  subperitoneal 
myomata.  Situated  in  the  anterior  wall,  just  beneath  the  mucosa,  was  a  myoma,  1.5  cm.  in  diameter.  The 
myoma  had  become  adherent  to  the  muscle  of  the  jjosterior  wall,  thus  partially  obliterating  the  uterine  cavity. 

At  a  the  uterine  mucosa  is  normal.  IX  gradually  becomes  thinner,  and  at  b  entirely  disappears.  This  is  due 
to  the  fact  that  the  subnmcous  myoma  of  the  anterior  wall  has  pressed  so  firmly  on  the  posterior  wall  that  the  two 
have  unite<i.     At  c,  where  little  or  no  pressure  has  existed,  the  nornuil  mucosa  is  again  found. 

Coalescence  of  the  uterine  walls  rarely  occurs,  but  is  not  infretjuently  simu- 
lated when  submucous  myomata  gre>atly  narrow  the  hmicn  of  the  cavity.  In 
such  cases,  however,  ihcy  have  iiici'cly  pushed  the  mucosa  in  fronl  of  them 
without  causing  fusion  with  the  nnicosa  of  the  opposite  wahs. 


Blood  in  the  Uterine  Cavity  . 

As  a  rule,  when  the  cavity  of  the  uterus  is  opened,  litth'  or  no  blood  is  found, 
but  occasionally,  as  in  Case  8738,  the  cavity  will  be  found  partially  or  completely 
filled  with  l)lood.  In  this  case  it  was  full  of  tarry  masses  and  recently  coagu- 
lated blood. 

In  Fig.  197  we  have  a  large  submucous  myoma  filling  the  entire  uterine  cavity 

♦Partial  obliteration  of  the  uterine  cavity,  due  to  foale.scence  of  tlie  uterine  waits,  was  also 
noted  in  Cases  2G06  (Path.  No.  19G),  27i:?  (Path.  No.  _>.-)()),  J. 'H 4  (Palli.  No.  ll.VJ),  and  3319 
(Path.  No.  592).     In  the  last  case,  however,  tlicrc  was  tulxTculosis  of  the  endometrium. 


310 


:\IYU.MATA    OF    THK    UTF.RUS. 


aiul  also  clilatinji  the  cervical  canal.     In  the  ni)j)cr  })art  of  the  cavity  the  surface 
is  covered  Avitii  a  large  clot. 

If  blood  is  })resent  in  the  cavity,  the  amount  will  depend  upon  the  copiousness 
of  the  flow  and  the  ease  or  dilliculty  with  which  it  can  escape  from  the  cervix. 

Pus  IN  THE  Uterine  Cavity  in  Cases  of  Myoma. 

A  definite  ])y()metra  is  rarely  associated  with  myomata,  but  occasionally  at 
operation  a  small  amount  of  pus  is  found  in  the  uterine  cavity.  In  Case  2098, 
for  example,  the  lower  abdomen  was  filled  with  a  myomatous  uterus,  and  a 
.small  quantity  of  ])us  was  found  in  the  cavity. 

In  Case  12430  the  lai'o;e  multinodulai-  uterus  was  adhei'ent  in  the  j^'lvis,  and 


Fic;.  197. — A  LARot;  Ci.ot  ix  the  L'terixe  C.wity.      Kh  nat-  si^e.) 
Gyn.  No.  14.37.3.  Path.  No.  12090.     The  anterior  uterine  wall  is  of  normal  thickness.     Filling  the  uterus 
is  a  pear-shaped  submucous  myoma.     Covering  the  surface  of  the  myoma,  in  the  upper  part  of  the  cavity,  is 
a  large  clot.     The  small  connections    passing  from  the  uterine  wall   to  the  myoma  are  drawn   nut   and  rather 
elastic   threads,   composefl   of  fibrin,  with   red  blood-corpuscles  in  the  meshes. 

also  liniily  fixed  to  a  looj)  of  small  bowel.  Hoth  tubes  were  tilled  with  ])us. 
The  cavity  of  the  uterus  contained  |)us.  The  uterine  cavity  had  evidently  long 
l)een  the  seat  of  an  inflammation,  as  the  mucosa  had  been  rej)laced  by  granula- 
tion ti.s.sue. 

In  all  cases  in  which  there  is  a  foul  discharge  from  the  uterus,  any  alxlominal 
operation  should  be  postponed  until  the  discharge  has  been  eliminated,  otherwise 
there  will  be  great  danger  of  infection.  Of  course,  in  some  ca.ses  immediate 
operation  is  im})erative,  irrespective  of  such  risks. 


CONDITION  OF  THE  MUCOSA  LINING  THE  UTERINE  CAVITY  IN  CASES  OF 

MYOMATA. 

(Hands  running  paralh'l  to  the  surface  of  the  mucosa. 

Extension  of  the  muscle  into  the  mucosa. 


THE    COXDITIOX    OF    THK    UTKRIXK    MUCOSA    IX    CASES    OF    .MYO.MA. 


311 


Alterations  in  the  l)lood- vessels  of  the  mucosa. 

Thrombosis  of  the  veins  in  the  mucosa. 

Unusual  gland  shaj^es. 

Edema. 

Dilatation  of  the  uterine  glands. 

Gland  hypcrtroi)hy. 

Uterine  polyj)i. 

Atypical  changes  in  the  epithelium  lining  the  uterine  cavity. 

Adenocarcinoma. 

A  small  myoma  developing  in  th(>  uterine  nni- 
cosa. 

Endometritis. 

Tuberculosis  of  the  endometrium. 

If  the  myomata  are  so  situated  that  the  uterine 
cavity  is  not  encroached  upon  nor  enlarged,  and 
provided  the  tubes  are  normal,  as  a  rule  it  may  be 
assumed  that  the  uterine  mucosa  is  normal.  Oc- 
casionally, however,  it  is  thicker  than  usual,  as 
appears  in  Fig.  19(S,  or  in  rare  instances  it  is  gath- 
ered up  into  ii-regular  mounds  forming  localized 
areas  of  very  thick  nmcosa,  as  seen  in  Fig.  199. 

When  an  interstitial  myoma  reaches  large  di- 
mensions, it  usually  produces  a  corresponding 
lengthening  and  broadening  of  the  uterine  cavity. 
Under  these  circumstances  the  normal  amount  of 
mucosa  has  to  cover  an  area  sometimes  twice,  or 
in  other  instances  four  or  more  times  as  great  as 
before,  and  naturally  will  then  ]w  only  one-foui'th 
the  usual  thickness.  Fig.  200  shows  a  small  seg- 
ment of  normal  mucosa  from  an  enlarged  uterine 
cavity.  If  the  myoma  is  small  or  of  moderate 
size,  it  will  almost  always  become  subpei-itoneal 
or  submucous.  If  it  })asses  toward  the  cavity  of 
the  uterus,  the  overlying  nuicosa  gradually  becomes 
thinner,  as  is  well  seen  in  l''ig.  1202.     This  mechanical 

thinning  out  becomes  more  and  iiioi-e  marked,  until  Hnally  little  or  no  mucosa 
can  be  detected  over  the  more  jjroniinent  part  of  the  tuiiioi-.  and  sometimes  it 
is  clearly  evident,  even  macroscopically,  that  this  portion  is  toiahy  dcNoid  of 
a  mucosa,  ^^'hen  the  myoma  is  small,  the  tension  on  the  mucosa  is  naturaUy 
not  as  great,  and  the  tumor,  even  though  subnuicous  and  |)edunculated,  may 
still  have  a  lilieral  covering  of  mucosa.  In  Fig.  201  we  have  an  example  of 
a  young  myoma  foi'cing  its  way  through  the  mucosa  into  the  uterine  cavity. 
The  myoma  is  \'irtually   plowing  through  the  nmcosa,  i)ushing  it  to  either  side. 


Fig.  198. — Thickeni.vg  ok  thk 
Uterine  Mucosa.  (X  8  diam.) 
Gyn.  No.  2706.  Path.  No. 
245.  The  uterus  contained  small 
interstitial  and  subperitoneal  myo- 
mata. The  uterine  cavity  was  4.5 
cm.  long.  The  mucosa  is  consider- 
ably thickened,  and  consequently 
tlic  glands  are  much  lengthened. 
They  are  normal,  a  indicates  the 
surface ei)itheliuni,  and  li  the  irregu- 
lar line  of  jimcliiin  lictween  the 
inuciisa  and  the  muscle. 


312 


MVOMATA    OF    THE    UTf:RUS. 


and  also   causing   atrophy  over   the   most    prominent   portion  of  the  nodule, 
whereas  the  mucosa  at  the  sides  is  much  thicker  than  usual. 


'■■cyo\  „  _v>> 


r-     ■.%. 


k  0--;  ,^.^  ... 


^7-V. 


f)_^.. 


a 


Fig.  199. — Thickening  of  the  Mucosa  in  a  Myomatous  Uterus.  (X  8  diam.) 
Gyn.  No.  .3614.  Path.  No.  788.  The  uterus  was  11x9x9  em.,  and  covered  with  den.se  adhesions.  Its  walls 
showed  diffuse  myomatous  thickening,  in  places  reaching  5  cm.  .An  interstitial  myoita,  9  cm.  in  diameter,  was 
also  present.  The  uterine  cavity  was  6  cm.  in  length,  and  the  mucosa  in  the  upper  part  of  the  cavity  wa.s  gathered 
up  into  mounds,  varjing  from  1  to  3  cm.  in  diameter,  and  projecting  from  1  to  8  mm.  into  the  cavity.  The  section 
is  from  one  of  these  elevations,  a  and  a'  indicate  the  line  of  junction  between  the  mucosa  and  the  myoma.  The 
surface  epithelium  is  intact.  Many  of  the  glands,  especially  in  their  deeper  portions,  are  dilated.  The  stroma  in 
the  superficial  portion  is  somewhat  rarefied.  It  also  contains  many  capillaries,  one  of  which  is  seen  at  b.  Near 
the  muscle  are  numerous  vacuoles,  indicated  by  c. 

^^'ith  the  continued  inward  progress  of  the  myoma  the  mucosa  becomes 
thinner  and  thinner,  until  all  trace  of  the  glands  disa)i)»ears  and  merely  the  surface 


^m^^'^ 


Fig.  200. — Moderate  Thinning-out  of  the  Mucosa  Over  a  Submucou.s  M  vo.ma.     ( X  ^i  diam.) 

Path.  No.  591.    The  globular  uterus  measured  17  x  17x12  cm.     The  uterine  cavity  was  15  cm.  in  length,  11  cm. 

in  breadth,  and  projecting  into  it  from  the  posterior  wall  was  a  submucous  myoma,  13  x  11  cm.  The  section  is  from 

the  surface  of  this  large  submucous  tumor,     a  is  the  mucosa,  which  is  much  thinner  than  usual,  but  otherwise 

normal,     b  is  a  thin  layer  of  uterine  muscle  separating  the  mucosa  from  the  underlying  myomatous  tissue  (m). 


epithelium  and  a  zone  of  underlying  stroma  are  left,  .separating  the  myoma  from 
the  uterine  cavitv.     This  is  clearlv  shown  in  Fig.  203.     The  stroma  becomes  more 


THE    COXDITIOX    OP^    THE    UTERIXE    MUCOSA    IX    CASES    OF    MYOMA.  313 

and  more  thinned  out,  until  only  a  few  layers  of  stroma  cells  are  interposed  be- 
tween the  myoma  and  the  surface  epithehum  (Fig.  204).  Finally,  when  the 
myoma  projects  far  into  the  cavity,  the  mucosa  may  be  represented  merely  by 


■-^ 


Fig.  201. — A  Small  Myoma  Pushing  Through  thp:  Mucosa.      (X  12  diam.) 
Path.  No.  5.33.     a  is  the  surface  epithehum.     The  myoma  is  pushing  the  mucosa  to  either  side  and  is  causing 
a  thinning-out  of  the  mucosa  over  the  most  prominent  portion  of  the  tumor.     The  mucosa  is  thicker  on  the  sides  of 
the  myoma  than  it  is  elsewhere. 

a  layer  of  somewhat  flattened  epithelium,  resting  directly  on  the  myoma.     Such 
a  condition  is  presented  in  Fig.  205. 

The  next  stage  is  so  well  exemplified  in  Case  8767  (Path.  No.  4959)  that  a 


'/Ki--^*«»-?tj. 


^  ■  '^^^^ 


-  y 


MOL. 


^U-li^'!'K>-7l  '"^CL'ZW.Ji  -.Vi'".'.-^-' 


Fig.  202. — Thi.\nin<;  out  of  the  Mucosa  Over  a  Submucous  Myoma.     (X  iij  diam.) 
Oyn.  No.  3008.  Path.  No.  43.').     a  indicates  the  normal  thickness  of  the  mucosa,  and  b  the  layer  of  muscle 
separating  the  submucous  myoma  from  the  mucosa.     Toward  the  left  the  myoma  becomes  more  prominent,  and 
the  muscle  and   mucosa  gradually   become   thinner  until  at  a'  all  traces  of   the  glands  have  liisappcaicd.  and  the 
mucosa  is  represented  merely  by  the  surface  epithelium  and  a  certain  amount  of  underlying  stroma. 

detailed  description  will  b(;  given.  The  specimen  consisted  of  a  globular  uterus, 
averaging  18  em.  in  diameter.  The  great  increa.^e  in  size  was  due  to  the  pres- 
ence of  an  interstitial  myoma,  approximately  17  cm.  in  diameter,  and  occupying 
the  posterior  wall.     The  uterine  cavity  was  15  cm.  in  length,  and  its  mucosa 


314 


MVOMATA    OF    THK    UTERI'S. 


avcragecl  about  1  iimi.  in  tliickncss.  At  one  point  oviT  the  suhimicous  myoma 
the  mucosa  had  entirely  (lisa|)])eare(l  tVoni  an  area  measurinii  7x5  cm.  The 
myoma  here  was  dark  l)ro\vn  in  cohjr  and  somewhat  roughened.  On  histologic 
examination,  the  mucosa  hning  the  uterine  cavity  was  found  to  be  perfectly 


>?-■•  :^  -  -.-^^.t   -^-V-- •■-'"' 1,*^  -^ 


3  •f^AK*-.<ihP/i.-. 


Fig.  203. — Atrophy  of  the  Mucos.v  Over  a  Submucous  Mvoma.     (X  140  diam.) 
Gyn.  No.  .3218.     Path.  No.  .539.    The  surface  epithelium  (a)  is  normal,     b  is  the  zone  of  underlying  stroma, 
devoid  of  glands;  c  is  the  muscle.     The  myomatous  tissue  lies  immediately  beneath  this.     A  few  strands  of  muscle 
are  passing  up  into  the  stroma  at  d. 

normal,  but  near  the  denuded  area  it  had  become  thinner  and  thnmer,  until 
nothing  but  surface  epithelium  remained.  This  finally  disappeared,  and  the 
myomatous  tissue  which  had  undergone  hyaline  transformation  now  formed  the 
surface.  Scattered  throughout  the  hyaline  material  were  numerous  polymor- 
phonuclear leukocytes.  The  next  step 
would  be  breaking  down  of  the  degen- 
erated myomatous  tissue,  with  a  speedy 
formation  of  a  sloughing  submucous 
myoma. 

In  some  cases  the  myoinata  are  very 
abundant,  and  literally  pave  the  uterine 
cavity.  In  .such  cases  the  walls  suggest 
a  mosaic.  Over  the  myomata  the  mu- 
cosa is  very  thin,   whereas  the  spaces     Fig.  204.— marked  thi.nm.ng-out  of  the  mucosa 

.  Over   a   Submucous    Myoma.     (X  140  diam.) 

between  myomata  arc  hlled  with  mu-  ^^^    ^^   3^49    p^^j,    j^„    ggs.   a  is  the 

COSa,  which   is   often   injected   and    much       normal  surface  epithelium.     It  is  separated  from  the 

myomatous  muscle  (c)  merely  by  (a)  narrow  zone  of 
thickened.  stroma  (b). 

Case     No.    2658    (Path.    Xo.    213) 
afforded  an  excellent  example  of  such  a  condition.     The  uterus  was  ajjproxi- 
mately   globular,  being  13  x  11  x  11  cm.      Scattered    throughout     the    walls 
were  many   .small   myomata.     The   uterine  cavity  was   5  cm.  in  length,  and 
projecting    into    it    from    the    top    were    two    pedunculated    myomata,    the 


C{5 


THE    COXDITIOX    OK    THK    UTERINE    MUCOSA    IN    CASES    OF    MYO.MA.  315 

larger  Ix'ing  o  cm.   in   (lianieter.     The  entire  inner  surface  of  the  uterus  was 


H.^r^.it' 


Jiu.  20o. — A  Submucous  JIvoma  Almost  Dkvoid  ok  Mucosa.      (X  41  diam.) 
Gyn.  No.  329.3.     Path.  No.  583.     The  surface  epithelium  (a)  is  all  that  remains  of  the  mucosa.    It  rests  directly  on 

the  myomatous  tissue. 


'■^i'J'  ?' 


"'l*^'   ".'(V" 


^fM 


^-^~S>-«l0><Si-.y.^.^  ,-,, . 


fc 


'■■X-. 


Fici.  20G. — Marked  Thickkninc  ok  tiik  Utkrink  Mucosa  in  a   I)KrnKssioN   Hi;r\vi;i;.\    .Myomatous  Nodi'lks. 

(X  5  (liam.) 

Gyn  No.  2658.  Path.  No.  213.  'I'he  uterus  \va-<  enlarged,  measuring  13  x  11  \  11  cm.  Scattered  Ihrnugli- 
out  its  walls  were  myomata,  varying  from  0.5  to  5  cm.  in  diameter. 

The  uterine  cavity  was  S'cni.  in  length.  Projecting  into  it  from  llic  lop  were  two  pciluiiculalcd  suhnmcous 
myomata.  The  whole  inner  surface  of  tlie  uterus  was  paved  with  small,  pearly  while  m.\ onial.-i,  v:u\ing  frum 
3  mm.  to  3  cm.  in  diameter,  the  intervening  si)accs  being  occupied  l)y  iii.iected  mucosa. 

The  i)icture  represents  the  cleft  between  myomata,  where  the  nuicosa  readied  8  nun.  in  thickness.  Scattered 
everywhere  throughout  the  muscle  are  myomata  of  various  sizes.  To  the  left  the  nuicosa  is  fairly  well  preserved. 
In  the  cleft  it  is  very  thick,  but  otherwise  normal.  At  «  a  young  )>olyp  is  developing.  .\t  b  the  mucosa  is  repre- 
sented by  one  layer  of  cyiiridric  cpithcliuni  which  rests  directly  im  the  m,\(imatons  muscle. 


paved  witii  small,  pearly'  white  myomata,  N'aiA'iiig  from  ().'.]  to  .'5  cm.  in  diameter. 
The  inteiA'eniiig  sj)a('es  wei'e  occupied  hy  injected  imicosa,  which   in  one  ch'ft 


316  MYOMATA    OF    THK    UTERUS. 

reached  8  mm.  in  thickness.     Histologic  examination  showed  that  the  mucosa 
was  in  phices  virtually  al)sent,  but  at  other  points  reached  8  mm.  in  thickness 
(Fig.  206).     That  covering  the  submucous  nodules  over  their  most  prominent 
{)ortion    was     represent  etl 
by  one  layer  of  cylindric 
epithelium   resting    almost 


5^5- 


Fi<;.  207. — Gland  Hypertrophy  in  a  Cleft  Between  Myomatous  Nodules.  (X  7  diam.) 
J.  ( H.  A.  K.,  DecemberO,  ISQOV  Path.  No.  3674.  The  slightly  irregular  myomatous  uterus  measured  13  x  10  x  10 
cm.  Scattered  throughout  its  walls  were  myomata,  the  largest  7  cm.  in  diameter.  The  uterine  cavity  was  ap- 
proximately 10  cm.  in  length,  but  much  distorted  and  narrowed  by  submucous  nodules.  The  mucosa  was  smooth. 
Over  the  submucous  nodules  it  wa,s  as  thin  as  parchment,  but  where  not  subjected  to  pressure,  reached  from  2  to 
3  mm.  in  thickness. 

On  histologic  examination,  the  mucosa  presents  an  undulating  surface  and  an  intact  surface  epithelium. 
Over  the  prominent  portion  of  the  submucous  myomata  it  consists  merely  of  a  narrow  layer  of  stroma  covered  with 
epithelium,  but  devoid  of  glands.  In  the  protected  areas  the  mucosa  was  thickened.  The  picture  represents  such 
an  area.  At  c  and  c'  the  surface  epitheUum  rests  directly  on  the  muscle,  but  in  the  cleft  becomes  even  thicker  than 
normal.  It  shows  tj-pical  gland  hypertrophy,  especially  well  seen  at  a.  Some  of  the  glands,  as  at  b,  are  dilated. 
m  is  a  small  myoma. 

directly  on  the  muscular  tissue.     Some  distance  from  the  most  prominent  por- 
tion of  these  tumors  the  mucosa  had  regained  its  normal  thickness. 

In  a  few  cases  the  thickened  mucosa  in  the  crevices  between  myomata  showed 
typical  gland  hyjieitrophy,  as  seen  in  Fig.  207. 

Glands  Running  Parallel  to  the  Surface  of  the  Mucosa. 
It  is  no  uncommon  thing  to  see  the  deeper  portions  of  a  gland  running  parallel 
with,  instead  of  at  right  angles  to,  the  surface.     This  is  especially  prone  to  occur 
over  the  less  prominent   portions  of  a  submucous  myoma.     In  such  cases  it 


THE    COXDITIOX    OF    THE    UTERINE    MUCOSA    IX    CASES    OF    MYOMA.  317 

would  seem  that,  with  the  ingrowth  of  the  myoma,  the  deeper  portions  of  the 
glands  are  pressed  upward  until  they  are  at  right  angles  to  their  superficial  por- 
tions. This  explanation  will  apply  only  to  a  certain  percentage  of  cases,  as  we 
have  not  infrequently  seen  this  deflection  of  the  glands  in  the  absence  of  sub- 
mucous myomata. 

Extension  of  the  Muscle  into  the  Mucosa. 

It  is  a  common  occurrence  to  find  one  or  more  uterine  glands  extending  a 
short  distance  into  the  muscle,  especially  if  there  be  an  adenomyomatous  ten- 
dency, but  the  extension  of  muscle-bundles  into  the  mucosa  is  relatively  rare. 

In  Case  2852  (Path.  No.  347)  some  of  the  uterine  glands  were  much  dilated, 
the  stroma  of  the  mucosa  showed  moderate  hemorrhage  in  its  sui:)erficial  portion, 
and  here  and  there  bundles  of  muscle-fibers  had  extended  into  it. 

The  picture  in  Case  3113  (Path.  No.  487)  was  even  more  striking.  The 
mucosa  was  very  atrophic.  The  surface  epithelium  was  intact,  the  glands  were 
few  in  number,  small,  and  round  on  cross-section.  The  stroma  of  the  mucosa 
showed  a  considerable  amount  of  infiltration  with  small  round  cells,  and  non- 
striped  muscle-fibers  were  seen  passing  up  into  the  stroma  of  the  mucosa  nearly 
as  far  as  the  surface  epithelium. 

Alterations  in  the  Blood-vessels  of  the  Uterine  Mucosa  in  Myoma  Cases. 

As  a  rule,  the  mucosa  will  jjresent  the  usual  appearance  if  the  tumors  do  not 
encroach  upon  it,  and  even  if  there  is  a  marked  projection  of  the  tumor  into  the; 
cavity,  little  or  no  change  in  the  mucosa  may  be  noted. 

In  a  moderate  number  of  the  cases  the  mucosa  is  uniformly  bright  red,  ap- 
parently owing  to  an  injection  of  the  capillaries.  More  common  than  this  are 
foci  of  ecchymosis.  These  ecchymotic  spots,  if  recent,  are  bright  red  in  color,  and 
appear  as  splotches  of  red.  They  are  irregular  in  outline,  and  sharply  difTeren- 
tiated  from  the  surrounding  and  normal  mucosa.  Sometimes  they  are  found 
in  a  mucosa  of  the  normal  thickness,  l)ut  are  more  likely  to  l)e  noted  over  the 
prominent  surface  of  a  large  submucous  myoma.  As  the  hemorrhagic  areas  be- 
come older,  they  change  in  color,  being  in  turn  dark  red  and  tlien  almost  black. 

^Miere  the  mucosa  is  exceedingly  thin,  dilated  veins  beneath  it  are  often 
clearly  visible.  These  veins  are  often  greatly  increased  in  size  when  large  myo- 
mata are  present. 

On  histologic  examination  one  Imiuently  notes  an  abuiidaiice  and  much 
dilatation  of  the  capillaries  in  the  superficial  portions  of  the  mucosa.  In  I'ig.  208 
we  have  an  example  of  a  mucosa  showing  mark(>(l  dilatation  of  the  larg(>r  veins. 
This  mucous  membrane  is  otherwise  unaltered. 

In  the  cases  in  which  ecchymosis  is  noted,  there  is  usually  nnich  free  blood  in 
the  stroma  of  the  mucosa.  This  may  be  fresh,  as  in  I-'igs.  20*1  and  210,  or  show  a 
moderate  degree  of  disintegration,  in  most  cases  all  trace  of  the  hemorrhage 
eventually  disappears,  but  occasionally  l)lo()(l-i)iginent  remains.     In  Case  3960 


318 


MVOMATA    OF   THK    UTERUS. 


(Path.  Xo.  971),  for  cxaiiiplc  the  uterine  cavity  was  3  cin.  in  length,  3  cm.  in 
l)rea(lth.  and  its  smooth  mucosa  presented  numerous  fine  ecchymoses.  In  sec- 
tions from  these  areas  the  surface  epitheUum  was  intact  and  the  glantls  were 


^    D  ^ 


'--^.<  ^*^ 


Fn;.  208. — Marked  Dil.vtation  of  the  Vei.ns  of  the  Uterine  Mucos.\.     (X  11  diaiu.) 
Path.  No.  ,524.     a  is  the  mucosa,  b,  the  underlying  muscle.     The  surface  epithelium  and  the  glands  are  normal 

but  the  veins  (c)  are  greatly  dilated. 

normal.     The  stroma  of  the   mucosa  showed   slight  small-rouiid-ccllcd  infiltra- 
tion, and  there  were  deposits  of  yellowish-l)rown,  granular  pigment. 

In  Case  3492  (Path.  No.  711)  a  myoma,  10  cm.  in  diameter,  projected  into  the 
uterine  cavity.     Scattered  throughout  the  mucosa  were  numerous  patches  of 


..,va^'JC:;?i&  <£  ^i  > 


I'll..   _'it'.i.     lliMoKuiiAGE  INTO  THE  Uterine   Micn-v.        ■     130  diam.) 
Gyn.  No.  3038.     Path.  No.  452.     The  surface  epithelium  a  is  normal.     .\t  b  it  ha.s  been  cut  on  the  bevel,  and 
thus  appears  several  layers  thick.     The  uterine  glands  are  normal,  but  scattered  throughout  the  stroma  are  quan- 
tities of  fresh  blood,  and  in  places  the  stroma-cells  lie  totally  isolated  from  one  another. 

ecchymosis.  Histologic  examination  showed  the  mucosa  co\'enng  the  sub- 
mucous myoma  to  be  atrophic,  and  there  was  al.so  edema,  ^^'here  the  ecchy- 
motic  patches  were  noted,  large  quantities  of  an  almost  l)lack  pigment  were  found 
in  the  stroma.     This    pigment    occurred    in    irregular    clumps    or   as    minute 


THE    COXDITIOX    OF   THE    UTERINE    MUCOSA    IX    CASES    OF    MYOMA. 


!19 


specks.     AMiether  or  not  it  was  coiitainod  in  the  cells  it  was  difficult  to  deter- 
mine. 


»t';r 


i-^ 
V""?-*---:'' 


-.^.^.t.....    »l 


Fig.  210. — Hkmohhiiac;i;  inio  rm.  Mrcus  v.      (   ■    'JOdiam.i 
Gyn.  No.  3281.     Path.  No.  573.     The  surface  epithelium  (a)  is  intact,  and  the  glands  are  normal.     The 
stroma  of  the  mucosa  shows  marked   hemorrhage   (b).     The  large,  irregular,  empty  areas  were  also  filled  with 
blood.     This  has  clrr)])i)e(l  out,  owing  to  its  crumbling  character.     The  veins  of  the  mucosa  are  mucli  dilated  (c). 


Fig.  211. — Rup'riiu-.  vmih  SiJbcik.>.iUK.M    Thhombosis  ok  a  V'i.in  ut    iuk  I  ii.niM-,  .Mitn.-A  o\  i-,u   v  SrnMi'oous 

Myoma.     (X  100  diam.) 
Gyn.  No.  8354.     Path.  No.  4539.     a  represents  the  remnant  of  the  atrophic  uterine  mucosa  covering  the  large 
submucous  myoma;  b  is  the  underlying  muscle.     Occui)ying  the  tiitper  pail  of  the  field  is  a  large  vein.     This,  at 
c,  still  contains  normal  blootl,  but  at  d  is  filled  with  a  thrombus  which  reaches  to  and  opens  on  tl\e  sinface.      There 
has  undoubtedly  been  a  recent  hemorrhage  from  this  vein. 


It  is  most  exceptional  to  find  any  e\ideiu'e  of  a  deliiiite  l)leedin<i  \'essel  in  the 


320 


MYOMATA    OF   THE    UTERUS. 


mucosa.  The  surface  epithelium  is  invariably  intact,  and  the  bleeding  seems  to 
be  just  a  general  oozing  from  the  vessels  in  the  mucosa,  without  any  especial 
injury  to  their  walls.  In  all  the  cases  just  described  the  hemorrhage  was  into  the 
mucosa,  and  the  surface  was  smooth.  In  Case  7688,  however,  in  which  the  cavity 
of  the  uterus  was  di.^torted  by  interstitial  and  submucous  myomata,  the  mucosa 
showed  large  heuiorrhagic  areas  which,  to  a  great  extent,  were  covered  with  fibrin 
and  blood. 


-d 


i-f^ 


Tig.  212. —  Hkam  HIM.  oi-  a 
Uterine  Gland.  (X  50 
diam.) 

Gyn.  No.  3008.  Path. 
No.  435.  The  uterus  con- 
tained subperitoneal,  inter- 
stitial, and  submucous  myo- 
mata. a  is  the  point  at  which 
the  tubular  gland  divides  into 
secondary  glands,  b  and  c. 
The  gland  c,  after  passing  a 
short  distance,  divides  into  d 
and  d'.  The  glandular  ei)ithe- 
lium  is  everywhere  normal, 
and  the  surrounding  glands 
and  stroma  present  the  usual 
appearance. 


Fig.  213. — An  Atypical  Uter- 
ine Gland.    (X  50  diam.) 

Gyn.  No.  3216.  Path. 
No.  534.  The  uterine  cavity 
in  this  case  was  not  encroached 
upon,  but  situated  in  the 
right  broad  ligament  was  a 
suppurating  myoma  (Fig. 
105,  p.  138).  The  surface 
epithelium  is  intact.  In  the 
depth  is  a  slightly  ililated 
gland  (a).  This  continues 
downward,  but  also  sends  off 
two  secondary  branches,  b  and 
c.  The  epithelium  of  all  the 
uterine  glands  is  normal,  and 
the  surrounding  stroma  is  un- 
altered. 


6 

Fig.  214. — An  Unusual  Uterine  Gland. 
(X  50  diam.) 

Gyn.  No.  3385.  Path.  No.  634.  The  multinod- 
ular inyomatous  uterus  measured  14  x  1.5  x  11  cm. 
The  nodules  were  chiefly  interstitial  and  subperitoneal. 

The  surface  of  the  mucosa  is  smooth,  and  the 
glands  near  the  surface  are  normal.  The  gland  (a^ 
can  be  traced  downward  and  to  the  right.  Us  ap- 
parently solid  character  is  due  to  the  fact  that  the 
section  ha,s  been  cut  through  the  margin,  instead  of 
through  the  center  of  the  gland.  At  b  it  spreads  out. 
It  is  continued  downward  and  also  to  the  left,  where 
it  gives  off  the  terminal  branches  c  and  d.  Although 
the  picture  is  a  most  unusual  one,  there  is  not  the 
slightest  suspicion  of  malignancy.  The  surrounding 
glands  and  their  intervening  stroma  are  normal. 


Thrombosis  of  Veins  in  the  Mucosa. 

In  Ca.se  6667  (Path.  No.  29U0)  there  was  a  history  of  a  sudden  hemorrhage 
four  years  before,  and  profuse  bleeding  each  month  after  that.  The  cavity  of 
the  uterus  was  occujiicd  by  one  large  and  two  small  myomata.  On  histologic 
examination  several  large  thin-walltHl  veins  of  the  atrophic  mucosa  were  found 
thrombosed. 

In  Case  8354  (Path.  Xo.  4.^39)  the  uterus  was  greatly  enlarged  as  a  result  of 


THE    CONDITION    OF    THK    UTERINE    MUCOSA    IN    CASES    OF   MYOMA. 


321 


siihpci'itonoal,  interstitial,  and  subinucoiis  inyoinata,  and  the  uterus  contained  a 
very  large  polyp  (Fig.  230,  j).  331).  The  mucosa  lining  the  uterine  cavity  was 
very  thin.  Its  surface  epithelium  was  intact,  but  flattened.  The  glands  were 
small.  The  stroma  showed  slight  infiltration,  and  occasionally  a  thrombosed 
vessel  simulating  to  a  liinit(>d  extent  a  young  tubercle.  At  one  point  at  least 
(Fig.  211)  the  walls  of  a  superficial  A'(Mn  had  given  way,  but  the  leak  had  been 
partially  controlled  b}'  a  thrombus. 

b         1)    b" 


Branching    of    a 
(X  50  diam.) 
Path.     No.    (>M. 


Fig.  215. — Marked 
Uterine  Gland 
Gyn.  No.  3385. 
The  gland  a  in  its  upper  portion  is  nor- 
mal, but  on  passing  toward  the  mus- 
cle, divides  into  the  .six  terminal 
branches  a',  a',  a',  a',  a',  a'.  Its  epithe- 
lium is  normal.  The  surrounding  ghinds 
present  the  usual  appearance,  and  the 
stroma  of  the  mucosa  is  unaltered. 


Fig.  216. — Marked  Branching  of  a  Uter- 
ine Gland.  (X  50  diam.) 
Gyn.  No.  3038.  Path.  No.  452.  The 
gland  a  in  the  lower  part  of  the  field  is 
slightly  dilated.  That  in  the  upper  part  is 
greatly  dilated  and  partially  filled  with  blood 
and  granular  detritus.  The  gland  sends  off 
the  terminal  branches  /),  //,  and  h",  while  the 
gland  between  b  and  b'  is  jirobably  a  l)ranch 
cut  at  another  level.  To  the  right  the  gland 
spreads  out  into  a  large  bay.  .\11  the  glands 
are  lined  with  normal  cylindric  epithelium 
and  the  surrounding  stroma  is  unaltered. 


Unusual  Shapes  of  the  Glands  Associated  with  Uterine  Myomata. 

As  has  been  said,  when  the  myomata  do  not  encroach  u))()n  the  uterine  cavity, 
the  latter  is  usually  of  the  nonnal  size:  the  mucosa  is  noniial  in  appearance,  and 
the  uterine  glands  are  of  the  usual  type,  l^ven  if  a  sul)inucous  myoma  is  ])i'esent , 
the  only  change  in  the  niucosa  will  be  a  ihinning-out . 

In  a  few  instances  we  ha\'e  found  unusu;il  |)alleiMs  in  I  he  gl;in(f'^;  some  of  the 
more  interesting  of  these  ai'e  shown  in  Figs.  212,  2I."!,  211,  21."),  and  21(). 

In  Fig.  212  we  see  a  dichot onions  branching,  ;ind  one  of  the  secoiidai'y  branches 
again  divides. 

21 


322  MVOMATA    OF    THK    ITKHIS. 

In  Fig.  213  wc  have  a  slightly  dilated  gland  in  the  d(']ith  of  the  mucosa  send- 
ing off  two  lateral  branches. 

In  Fig.  214  a  tubular  gland  can  be  followed  from  near  the  surface  into  the 
depth,  where  it  sends  off  branches  to  the  i-jglit  and  left.  One  of  these  again 
subdivides. 

In  Fig.  21 ")  a  gland  in  its  suj)erficial  portion  is  normal,  l)ut  in  the  depth  spreads 
out  and  apparently  ends  in  six  terminal  branches. 

The  large  ghuul  in  Fig.  21G  is  considerably  dilated,  and  spreads  out  into  three 
terminal  branches. 

The  glands  in  each  case  are  lined  with  normal  cylindric  epithelium,  and  are 


d 

Fiii.   217. — Ki)i-.MA  OK  THE  Utkrink  MicosA.      (X   130  diam.) 
Gyn.  No.  3209.     Path.  No.  540.     Separating  the  surface  epithelium  from  the  mucosa  at  a  and  b  is  coagulated 
serous  fiuid.     The  uterine  glands  are  normal  in  appearance.     The  stroma  is  very  edematous,  as  is  particularly  well 
seen  at  c.     Scattered  throughout  the  coagulated  serum  are  many  small  vacuoles,  one  of  which  is  indicated  by  d. 
.\t  e  the  stroma-cells  are  arranged  aroimd  a  vacuole  resembling  a  small  gland. 

surrounded  by  the  chai'acteristic  stroma  of  the  muco.sa.     In  none  of  them  is  there 
the  slightest  suspicion  of  malignancy. 

Edema  of  the  Uterine  Mucosa. 

Edema  is  usually  rec(jgnized  by  the  succulent  character  of  the  tissue  in  which 
it  is  found,  and  by  the  escape  of  serous  fluid  from  the  cut  surfaces.  The  uterine 
mucosa  has  a  glistening,  ti-anslueent  appearance,  so  that  edema  might  very 
readily  be  thought  to  lie  jjresent,  when  in  reality  none  exists.  Hie  diagno.sis,  as 
a  rule,  can  be  made  only  on  histologic  examination. 

Fdema  of  the  muco.sa  is  rare  and,  when  met  with,  is  usually  limited  to  the 
superficial  portions,  and  is  not  found  neai-  the  muscle.     It  may  be  localized  or 


THE    COXDITIOX    OF    THE    UTERIXE    MUCOSA    IX    CASES    OF   MYOMA. 


323 


uniform  throughout  the  cavity.     It  occurs  irrcs})ective  of  the  presence  or  ab- 
sence of  submucous  myomata. 

The  surface  epithehum  is  intact,  and  the  glands  are  usually  normal.  The 
stroma  cells  are  separated  from  one  another  by  a  granular  material  which  takes 
the  eosin  stain.  Scattered  throughout  it  are  large  or  small  vacuoles.  The 
granular  material  is  undoul)tedly  c()agulate(l  scrum.  A  certain  amount  of  fibrin 
can  also  be  demonstrated    in  some   cases   bv  means   of  Weitjert's  stain.     Oc- 


rn   XL   c  o  ^ 


Fig.  218.— Dilated  Uterine  Glands  Over  a  Submucous  Myoma,  (i;  nat.  size.) 
Gyn.  No.  12490.  Path.  No.  9186.  As  soon  as  the  uterus  was  opened,  its  muscular  walls  contracted,  leaviiiR 
the  submucous  myoma  standing  out  prominently.  The  mucosa  over  the  submucous  nodule  is  very  thin,  and 
standing  out  shaqily  from  this,  are  the  cystic  glands  (a).  The  mucosa  (h)  at  the  ba-se  of  the  myoma  is  consideralily 
thickened.  That  lining  the  opposite  wall  is  gathered  up  into  folds,  owing  to  the  marked  contraction  of  the  walls  liS 
soon  a.s  the  uterus  was  opened. 

casionally  the  exudate  is  exceptionalh'  rich  in  albuiiiiii.  It  ihcii  forms  a  hoiiic- 
geneous  mass  that  takes  tlic  eosin  stain.  When  the  cdcina  is  \('i-y  pronounced, 
as  in  Fig.  217,  much  serum  is  j)oure(l  out  not  only  into  the  stroma,  but  also  into 
the  glands,  and  the  surface  epithelium  may  be  separated  from  the  stroma  by 
scnmi.  ()ccasionally  the  lyniith-N'csscls  in  the  underlying  nniscle  are  dilated, 
as  in  Case  4203  (Patii.  No.  UK;). 


Dilatation  of  the  Uterine  Glands. 
In  a  moderate  luimber  of  inyonia  cases  we  li;i\"e  found  slight   dilatation  of 
some  of  the  uterine  glands.     The  dilate(l  glands  may  be  present  in  an\'  part  of 


324 


MYU.MATA    OF    THE    UTERUS. 


the  cavity,  and  are  more  j)r()iie  to  occur  when  submucous  myomata  exist. 
The  smaller  ones  are  recognized  as  spheric  cysts,  O.o  to  1  mm.  or  more  in  diam- 
eter, and  filled  with  a  translucent  or  transparent  content.  If  the  mucosa  is 
atroj)hic.  these  small  cysts  .stand  out  prominently.  They  are  also  especially 
noticeable  in  uterine  i)()l\-pi. 

In  rare  instances  the  cysts  become  relatively  large,  as  in  Fig.  218,  in  which  we 
see  numerous  cysts,  .several  millimeters  in  diameter,  ])rojecting  from  the  atrophic 
muco.'^a  covering  the  submucous  myoma.  Another  striking  examj)le  of  cystic 
glands  is  furnished  by  Fig.  219.  Here  the  uterine  cavity  is  much  increased  in 
size,  and  the  muco.sa  over  a  large  submucous  nwoma  has  numerous  cysts  or 
blebs  projecting  from  its  surface.  These  cysts  tend  to  arrange  themselves  in 
rows;  they  have  exceedingly  fine  walls,  and  ramifying  over  their  surfaces  arc; 
delicate  traceries  of  blood-vessels.     They  are  filled  with  a  clear.  linij)id  fluid. 


Fic.  220. — Makkkdly  Dilated  Uterine  Glands,  v  ,\  '>  .liam.  - 
Gyn.  No.  3232.  Path.  No.  543.  The  section  embraces  one  of  the  dilated  glands  in  Fig.  219.  a  is  the  normal 
mucosa.  .\t  b  the  glands  show  cystic  changes.  The  smaller  cysts  are  irregular,  the  larger  spherical,  c  is  one  of 
the  markeilly  dilated  glands.  The  surface  epithelium  is  continued  over  it.  .\11  trace  of  an  epithelial  lining  has 
disappeared  from  the  inner  walls  of  the  greatly  dilateti  glands,  although  still  present  in  those  showing  only  moderate 
dilatation. 


Occasionally  the  (iilated  glands  contain  small  yellow  bodies  that  float  around 
in  the  clear  fluid.     These  bodies  usuall>-  consist  of  exfoliated  epithelial  cells. 

On  histologic  examination  the  glands  sho\ATng  moderate  dilatation  have  an 
intact  cylindric  epithelium.  They  may  be  empty,  as  in  Fig.  221,  or  contain  a 
granular  detritus  or  a  .solid  coagulum  resembling  a  hyaline  cast.  When  the 
glands  l)ecome  still  more  dilated,  the  epithelium  .sometimes  retains  its  normal 
form,  but  is  usually  flattened.  In  a  few  in.stances,  as  in  Case  3437,  the  epithelium 
may  show  ])roliferation,  being  several  layers  in  thickness. 

Where  marked  dilatation  occurs,  the  epithelium  may  entirely  disappear. 
In  Fig.  220  .some  glands  .show  slight  dilatation  and  are  irregular  in  contour. 
Tho.se  moderately  dilated  are  spheric,  whereas  the  one  .showing  great  dilatation 
is  irregularly  oval. 

An  example  of  gland  dilatation  of  a  marked  degree  is  furnished  by  Case  3133 
(Path.  No.  494).  The  uterus  was  pear-.sha|)e(l,  and  measured  36  x  32  x  32  cm 
The  uterine  cavdty  was  31  cm.  long,  and  varied  from  0  to  14  cm.  in  breadth.     Its 


Fig.  219. — Marked  Dilatation  of  the  Uterine  Glands  Over  a  Submucous  Myoma.     (J?  nat.  size.) 
Gyn.  No.  3232.     Path.  No.  543.     Mr.  Bnidel  painted  this  picture  within   a  few  minutes  after  the  uterus  was 
opened,  and  was  fortunate  in  getting  the  exact  colors  of  the  mucosa. 

Occupying  the  posterior  uterine  wall,  and  seen  in  hazy  outline,  is  a  myoma  15  cm.  in  diameter.  The  uterine 
cavity  is  much  increased  in  size.  The  mucosa  has  a  yellowish  tinge,  and  scattered  over  the  anterior  and  posterior 
walla  are  a  few  irregular  patches  of  ecchymosis.  Scattered  over  the  posterior  walls  are  numerous  cysts  varying 
from  1  to  7  mm.  in  diameter,  and  apparently  arranged  in  definite  rows.  The  larger  cysts  have  elevated  margins, 
are  sharply  defined,  and  project  fully  1  mm.  from  the  surface.  They  are  covered  with  a  delicate  membrane,  which 
is  everjT^'here  traversed  by  a  fine  network  of  blood-vessels.  The  blood-supply  of  these  cysts  reminds  one  somewhat 
of  the  vascular  arrangement  of  the  fundus  of  the  eye. 

For  the  histologic  appearances  of  the  cysts  see  Fig.  220. 


THE    CONDITION    OF    THE    UTERINE    MUCOSA    IN    CASES    OF    MYOMA.  325 

mucosa  was  atrophic,  and  j)rojc'('ting  into  the  cavity  from  the  upper  part  were 
three  large  polypi.  Situated  in  the  posterior  wall,  about  12  cm.  from  the  top  of 
the  cavity,  was  a  yellowish  area,  3  cm.  in  diameter.  From  this  mucus  mixed 
with  blood  escaped  into  the  uterine  cavity.     This  cavity  had  smooth  walls. 

On  histologic  examinatioii  marked  atrophy  of  the  mucosa  was  found,  and 
most  of  the  glands  had  disappeared.  The  cyst-like  cavity  seen  near  the  middle 
of  the  uterus,  and  communicating  with  the  uterine  ca\dty,  was  lined  with  one 
layer  of  epithelium  similar  to  that  covering  the  surface  of  the  mucosa.  This 
cavity  was  in  all  probability  a  dilated  uterine  gland.  The  fact  that  it  secreted 
mucus,  however,  suggests  the  possibility  of  a  cervical  origin. 

Gland  Hypertrophy. 

This  was  noted  in  several  cases.  \Mien  present,  it  was  usually  associated 
with  submucous  myomata,  and  even  macroscopically  the  mucosa  was  thicker  than 


Fk;.  221. — A  MoDKRATE  Grade  of  Dilatatiox  of  the  Glands.     (X  8  diam.) 
Gyn.   No.  2852.     Path.  No.  347.     The  mucosa  on  the  right  and  left  is  normal.     The  glands  in  the  central 
portion  are  more  convoluted  and  show  slight  dilatation.     Just  beneath  the  surface  is  a  markedly  dilated  and 
irregular  gland.     The  dilatation  has  produced  a  decided  elevation  of  the  surface  of  the  mucosa  at  this  p;>int. 

usual  (Fig.  207,  p.  316).  The  hy])('rtr()])hic  changes  were  almost  invariably 
limited  to  the  su])erficial  layers  of  the  mucosa.  The  cause  of  the  gland  hyjx'r- 
tropliy  is  unknown.  In  Case  7795  (Path.  No.  4055),  in  which  a  right  tubal 
pregnancy  existed,  the  exciting  factor  was  evident. 

Uterine  Polypi  Associated  with  Myomata. 

On  opening  the  cavity  of  a  myomatous  uterus  one  oi'  more  jxilypi  arc  not 
infrequently  found.  These  may  he  situated  in  any  i)ait  of  the  cavity,  i)ut  are 
more  prone  to  occur  in  the  u])per  part.  .\ii  cxaiiiiiiation  of  It  cases  in  which 
uterine  poly))i  were  present  showed  that  in  34  tlici-c  was  I  p()ly[):  in  5  there 
were  2,  and  in  5  cases  3  polypi;  thus  it  is  evident  that  the  polypi  usually  occur 
singly. 

The  polypi  were  found  in  large  and  small  myomatous  utci-i,  the  size  of  the 
organ  seeming  to  have  little  or  no  influence  (Jii  their  development. 

Some  of  the  polyjn  were  very  small,  as  in  Fig.  222.  and  a))peared  as  little  Hat 
and  yet  sharply  outlined  ele\-atioiis  from  the  sui-faee  of  the  mucosa.     'Ilie  relation 


326 


.MVO.MATA    OF   THK    ITKRUS. 


of  such  small  polyj)!  to  the  nuicosa  is  clcaHy  seen  in  Fig.  225,  where  the  polyp  is 
evidontlv  iiothinu-  iiioic  than  a  heaping  up  of  the  mucosa  at  a  given  point. 


My  oma 


'^%i.X, 


Fig.  222. — Three  Small  Polypi.     (I!   nat.  size.) 
Gyn.  No.  91.'?2.     Path.  No.  5286.     The  picture  represents  the  right  half  of  the  uterus.     The  right  tube  is  much 
thickened  near  the  cornu.     In  the  anterior  wall  is  a  myoma,  several  centimeters  in  diameter.     In   the  posterior 
wall  are  a  few  minute  tumors.     In  the  uterine  cavity  are  three  small  flat  polypi,  as  indicated  by  a.     Two  are  in  the 
upper  part  of  the  cavity;  one  is  near  the  internal  os. 


Fig.  223. — Small  Uterine  Polypi,     d'o  nat.  size.) 
.'^ut.  No.  869.     Path.  No.  1.3S2.     The  cervix  is  normal.     The  anterior  uterine  wall  is  thickened,  and  contains 
a  small  myoma.     Projecting  into  the  uterine  cavity  are  two  small  pedunculated  polyi)i,  and  between  them  and  to 
one  side  are  the  faint  outlines  of  a  smaller  one. 


As  the  poly])i  get  larger  they  become  somewhat  ixMlunculated,  as  seen  in 


THE    CONDITION    OF    THK    ITKHINE    MUCOSA    IN    CASES    OF    MYOMA.  327 

Figs.  223  and  224.  The  majority  have  broad  bases,  and  are  relatively  thin, 
being  not  over  1  to  2  mm.  in  thickness.  Nearly  all  of  them  point  downward. 
The  polyp  in  Case  3038  (Path.  No.  452)  is  on(>  of  the  rare  exceptions.  This  polyp 
was  1.5  cm.  long  and  4  mm.  broad;  it  was  attached  near  the  internal  os  and 
pointed  upward. 

The  polypi  are  usually  smooth,  and  consist  of  a  whitish-yellow,  semi-trans- 
lucent substance — uterine  mucosa.  Scattered  throughout  it  are  often  seen 
small  cystic  spaces — dilated  glands.  The  lower  and  free  margins  of  the  polypi 
are  often  deeply  injected,  as  a  result  of  hemorrhage  into  their  dependent  portions. 


Fig.  224. — Polypi  Associatki)  with  Utkkink  Myomata.  (.^  aat.  size.) 
Gyn.  No.  9707.  Path.  No.  5912.  The  appendages  are  normal.  The  uterus  had  been  opened  posteriorly. 
Springing  from  its  surface,  and  studding  its  walls,  are  myomata  of  various  sizes.  Occupying  the  greater  part  of 
the  cavity  is  a  long  and  partially  submucous  myoma.  Springing  from  the  left  side  of  tiie  fundus,  near  the  coriui, 
and  attached  by  a  delicate  iiedide,  is  a  sligiitly  lobulated  i)olyp,  several  centimeters  long.  Hanging  down  from  the 
top  of  the  cavity  is  a  second  but  smaller  pnlyp,  which  has  been  cut  in  two. 

The  uterine  mucosa  surrounding  the  polypi  ma\'  be  (.)f  the  normal  thicknes.s, 
atrophic,  or  even  show  an  increase  in  thickness. 

In  a  few  cases  the  mucosa  had  shown  a  marked  tendency  to  gathei'  into 
ridges  or  folds,  but  no  definite  poly|»i  had  developed.  In  Case  I*,)").')  (Path.  No. 
1484),  the  globuhir  uterus  had  a  caNity  bl  cm.  long  and  7  cm.  broad.  The  nnicosa 
covering  the  j)ostei'i()i'  wall  was  pale,  smooth,  and  a\'eraged  2  mm.  in  thickne.ss. 
This  surface  was  concave,  having  been  subjected  to  pressure  extorted  by  a  tumor 
occupying  the  anterior  wall.  Near  the  fundus,  the  nmcosa  was  gathered  u])  into 
a  broad  flat  mound,  3  cm.  in  diametei-  and  I  cm.  thick.  Its  mai'gins  wen* 
slightlv  injected. 


328 


MVOMATA    OF    THK    UTERUS. 


H  i  s  t  ()  1  ()  g  i  (•   a  j)  p  I'  a  r  a  ii  c  e  .s   o  f   p  o  1  y  jm    f  v  o  in    t  h  e   b  o  d  y   o  f 
the  uterus. 


Fk;.  225. — A  Very  Eakly  Stage  of  a  Uterine  Polyp,     (i   nat.  size.) 
Gyn.  No.  8368.     Path.  No.  4554.     The  appendages  are  normal.     The  uterus  has  been  opened  from  the  front. 
Growing  from  its  walls  are  subperitoneal,  interstitial,  and  submucous  myomata.     The  mucosa  of  the  posterior 
wall  is  atrophic;  that  of  the  anterior  wall  is  of  the  normal  thickness,  except  at  a,  where  it  forms  a  distinct  area  of 
thickening,  producing  a  cystic,  sessile  polj-p.     The  small  cj'st  in  the  polyp  is  a  dilated  gland. 

Uterine  polypi  are  nothing  more  than  portions  of  the  mucosa  that  have  been 
partiall}'  extruded,  and  with  the  succeeding  and  frequent  contractions  of  the 


6    f 


^^ 


/i/y. 


Fig.  226. — The  Beginm.ng  of  a  Uterine  Polyp.     CX  12  diam.) 
(Jyn.  No.  3130.     Path.  No.  499.     The  section  is  from  the  body.     To  the   right   and  left  is  normal  mucosa. 
In  the  center  the  mucosa  is  thicker,  and  forms  a  dome-like  elevation  from  the  surface.    Here  the  glands  are  very 
abundant.     In  time  this  elevated  portion  would  be  forced  more  into  the  cavity,  until  it  became  a  pedunculated 
polyp. 


uterus  have  been  forced  out  into  the  cavity.     P'ig.  226  is  an  excellent  examjile 
of  the  earliest  stage.     The  muco.si  on  either  side  is  relativclv  normal,  whereas  in 


THE    COXDITIOX    OF    THK    I'TERIX?:    MUCOSA    IX    CASES    OF   MYOMA. 


320 


the  center  it  is  Ix'iii*;'  heaixnl  up  into  a  dome-like  ele\'ation.  This  area  would, 
in  time,  be  pushed  farther  into  the  cavity  and  would   form  a  definite   polyp. 

If  the  uterine  mucosa  from  which  the  polyp  is  nipped  off  is  normal,  we  should 
expect  the  polyp  to  consist  of  normal  mueosa.  The  surface  of  the  polyp  is  usually 
smooth,  as  in  Fig.  226,  hut  may  be  wavy  in  outline.  The  majoritv  of  the  glands 
present  the  usual  appearance,  but  as  a  result  of  ()l)struetion,  some  of  them 
tend  to  become  cystic,  and  their  epithelium  flattened.  In  the  stroma  of  the  pedicle 
of  the  polyp  non-striated  nmscle  is  not  infrequently  found.  This  is  due  to  the 
fact  that  some  of  the  muscle  is  drawn  out  with  the  mucosa  as  it  is  being  extruded. 

The  mucosa  near  the  tip  of  the  ))olypi  often  shows  a  good  deal  of  hemor- 
rhage.    A  few  of  the  ])olypi  show  slight  disintegration:    the  gland  e{)ithelium 


Muscle 


Polyp 


Sjf  >^   > 


Fiii.  227. — A  Utkrine  Poi.yp.  (X  7  diain.) 
Gyri.  No.  7t)99.  Path.  No.  3948.  The  character  of  the  polyp  shows  that  it  is  from  the  body  of  the  uterus.  To 
the  left  is  uterine  mucosa,  which,  apart  from  slight  gland  dilatation,  is  normal,  a  indicates  the  to))  of  the  uterine 
cavity.  Attached  by  a  narrow  pedicle  is  an  oblong  polyp  with  a  rounded  end.  Its  surface  e|>ithelium  is  contiiuious 
with  that  lining  the  uterine  cavity,  and  represents  uterine  mueosa.  Many  of  its  glanils  are  dilated,  some  reach- 
ing large  proportions.  Where  marked  dilatation  has  occurred,  the  partitions  between  glands  have  in  places 
disappeared. 


ends  to  drop  off,  and  the  gland  cavities  are  (illcd  with  hyalin(--lik('  casts,  as  was 
noted  in  Case  3113  (Path.  No.  4S7). 

When  the  uterine  mucosa  is  the  seat  of  gland  hypeil  r()])liy,  the  poly])i,  as  a 
rule,  will  also  show  hypertrophy  of  the  glands.  This  was  especially  noticeable 
in  (;ise  12021  (Path.  No.  8002). 

Very  Large  Polypi. — That  uterine  |)oly|ti  may  reach  \-ery  Jai'ge  |)i'op()rtions  is 
clearly  demonstrated  by  the  following  cases: 

In  Case  5940  (Path.  No.  2212)  the  uterus  was  convtM-fed  into  a  nodular 
tumor,  ai)i)r()ximately  24  .\  10  cm.  The  uterine  ca\'ity  \\;is  1  I  cm.  in  ItMigth  and 
7  cm.  in  breadth.  4'he  ni)per  two-thirds  was  hllcd  with  three  I'emarkably  large 
polypi  (I"'igs.  22S  and  229).     The  lai'ger  of  the^c  nieasui'cil  7\  1  x  2..")  cm.     41ie 


330 


.\n(».MATA    OF    THK    ITHRUS. 


surfaces  dt'  the  polyj)!  were  injected,  traversed  by  branching  blood-vessels,  and 
studdcil  with  niiiuite  cysts,  avera^ng  1  mm.  in  diameter.  Sections  from  these 
])(>ly])i  showed  cyst-like  s))aces  scattennl  everywhere  througliout  their  substance, 
some  of  them  i-caching  .")  nun.  in  diameter. 

The  uterine  nuicosa  was  smooth,  ])ut  markedly  hemorrhagic.     The  myomata 
showed  lit  lie  tendency  to  enci'oach  on  the  uterine  cavity. 

Un  histologic  examination  all  the  ))oly])i  ])resented  the  same  j)icture.  Their 
sui'faces  were  compai'atively  smooth,  and  in  many  places  were  covered  with  one 
layer  of  epithelium.  Scattered 
tliroughout  the  stroma  of  the 
))()ly])i  weic  man\'  ty])ical  uter- 
ine glands.  The  cyst-like 
s|)aces  were  dilated  glands.  In 
the    majoi'ity  of  them  the  (^pi- 


H    B^'^-s.^r.M 


Fig.  229. — Cross-section  of  a  Very  Large  Uterine  Polyp 
IN  A  Case  of  Myoma.  (Nat.  size.) 
(jyn.  No.  5946.  Path.  No.  2242.  The  section  is  taken 
from  the  neighborhood  of  the  uterine  horn,  and  shows  a  small 
part  of  the  uterine  cavity  filled  with  polypi,  a  is  normal 
uterine  muscle;  b,  a  small  sessile  subperitoneal  myoma;  c, 
the  edge  of  a  large  myoma;  d  indicates  blood-vessels,  which, 
judging  from  their  thin  walls,  are  probably  veins;  e,  f,  and  g 
are  cross-sections  of  polypi.  Scattered  throughout  the  sub- 
stance of  the  polypi  are  large  and  small  cyst-like  spaces — dil.ated 
uterine  glands,  h  is  the  smooth  inner  surface  of  the  uterine 
cavity,      (.\fter  Thomas  Culleii.) 


I'k:.     22S. — Cuoss-sEfTiox      OK      a      Large 

Uterine  Polyp  i.n  a  Case  ok  Multiple 

Myomata.     (Nat.  size.) 

Gyn.  No.  5946.  Path.  No.  2242.  The 
section  is  taken  from  the  fundus,  a  is  nor- 
mal uterine  muscle;  b,  the  edge  of  a  large 
myoma;  c,  dilated  veins;  d  shows  a  cross- 
section  of  a  large  polyp.  Its  surface,  al- 
though undulating,  is  perfectly  smooth,  but 
on  section  it  presents  a  cystic  appearance, 
due  to  the  many  dilated  glands,  one  of 
which  reaches  at  least  5  mm.  in  diameter. 
The  polyp  has  a  broad  ba.se,  and  shows  lu) 
tendency  to  penetrate  the  muscle.  Histologic 
examination  shows  it  to  consist  of  practically 
normal  mucosa,  e  is  normal  mucosa  (.\fter 
Thomas  CuUen.) 

thelium  was  still  well  preserved.  In  not  a  few  ))laces,  however,  it  had  dropped 
off  in  ril)bons,  forming  irregular  skeins  in  the  gland-spaces,  and  at  first  sight 
offering  a  suggestion  of  malignancy.  The  ai)])earanc(\  howcwer,  was  due  to 
faulty  hardening.  The  stroma  of  the  mucosa  corr(>sponded  to  that  of  the  uter- 
ine mucosa. 

In  Case  8354  (Path.  No.  4.j;!i))  the  myomatous  uterus  was  24  x  20  x  lo  cm. 
The  uterine  cavity  was  13  cm.  long  and  7  cm.  broad  in  its  upi)er  portion.     The 


Fig.  230. — A  Very  Large  Uterine  Polyp  (j  nat.  size.) 
Gyn.  No.  8354.  Path.  No.  45.39.  The  myomatous  uterus  extended  to  the  umbilicus,  and  was  24  x  20  x  15  cm. 
It  is  literally  riddled  with  subperitoneal,  interstitial,  and  submucous  myomata.  Filling  the  upper  part  of  the 
uterine  cavity  is  a  lobulatetl  polyp  with  a  delicate  granular  surface,  strongly  suggestive  of  carcinoma.  This  polyp 
was  7  cm.  long,  5  cm.  broad,  and  3  cm.  in  thickness.  On  histologic  examination  it  was  found  to  be  composed  of 
uterine  mucosa,  showing  areas  of  gland  liypertrophy.      It  is  the  largest  uterine  polyj)  that  we  have  ever  seen. 


THE    CUXDITIOX    OF   THE    UTERINE    MUCOSA    IX    CASES    OF    MYOMA.  331 


332  MVOMATA    ()K    THK    UTERUS. 

mucosa  was  N-crv  thin.  Tlic  cliiof  interest  centered  in  a  mass  which  was  attached 
to  the  uterine  wall  l»y  a  deUcate  pedicle,  and  filled  almost  the  entire  cavity. 
This  mass  was  irreu;ular  in  shape,  somewhat  lobulated,  and  had  a  fine  granular 
surface  (Fig.  230).  It  measured  7x5x3  cm.  Its  granular  appearance  strongly 
suggested  carcinoma,  hut  it  showed  no  areas  of  disintegration.  On  section,  the 
growth  was  fairly  homogeneous  and  cut  like  cheese.  Scattercnl  throughout  it 
were  numerous  hemorrhagic  areas  and  many  dilated  blood-vessels. 

On  histologic  examination  the  growth  filling  the  uterine  cavity  was  found  to 
consist  essentially  of  mucosa.  Its  surface  was  covered  with  one  layei-  of  ej)itheli- 
um.  Its  glands  in  ))laces  were  normal;  at  other  jjoints  they  branched  a  great 
deal  or  show(>d  dilatation.  Some  areas  showetl  tyi)ical  gland  hypertrophy.  The 
stroma  of  the  polyp  was,  to  a  considerable  extent,  infiltrated  with  small  roimd 
cells.     The  growth  was  nothing  more  than  an  exceptionally  large  uterine  polyp. 

In  Oyn.  No.  12155  (Path.  No.  8723)  a  very  large  myoma  sprang  from  the  sur- 
face of  the  uterus,  whose  walls  were  studded. with  smaller  nodules.  The  uterine 
cavity  was  S  cm.  long  and  4  cm.  broad.  Projecting  into  the  cavity  from  the  toj) 
was  a  polyp  5  cm.  in  length,  3  cm.  in  breadth,  and  tapering  to  1  cm.  at  the  jxjint. 
It  bore  a  strong  resemblance  to  a  long  and  narrow  chicken's  liver,  was  spongy, 
and  apparently  con.sisted  of  mucosa.  Histologic  examination  proved  it  to  be  a 
simple  uterine  polyp.  Some  of  its  glands  had  l)een  imperfectly  preserved, 
and  the  epithelium  had  dropped  off  in  ribbons,  forming  a  skein-like  arrangement. 

Large  poly}H  were  also  noted  in  Case  1223-4  (Path.  No.  88-14).  The  uterus 
was  ii'regularly  nodular  and  measured  25  x  21  x  15  cm.  The  uterine  cavity  was 
balloon-shaped,  and  j^rojecting  into  it  were  several  m^'omata  and  three  polypi, 
the  largest  of  which  was  5.5  x  4  x  3  cm.  This  large  polyp,  on  histologic  examina- 
tion, showed  typical  gland  hypertrophy.  Such  large  polypi  as  have  just  been 
described  are,  of  course,  exceptionally  rare. 

Atypical  Changes  in  the  Epithelium  Lining  the  Uterine  Cavity. 

In  addition  to  the  cell-changes  found  in  endometritis  and  in  cancer,  we  have 
also  noted  in  a  few  cases  a  definite  tendency  in  \hv  surface  epithelium  to  pro- 
liferate. In  Case  3320  (Path.  No.  589),  in  which  the  uterus  was  greatly  enlarged 
from  the  presence  of  sub})eritoneal  and  interstitial  nn^omata,  the  epithelium 
covering  the  surface  of  the  mucosa  showed  a  slight  tendency  to  i)roliferate,  being 
two  or  three  layers  in  thickness  at  several  points. 

Proliferation  of  the  surface  e])itheliuin  was  aW)  noted  in  Case  3408  (Path. 
No.  659)  and  in  Case  6479  (Path.  No.  2700).  Occasionally  small  papillary 
outgrowths  may  be  detected  arising  from  the  surface  of  the  mucosa.  In  Case 
3133  (Path.  No.  494)  the  uterus  was  tremendously  enlarged  from  the  presence 
of  an  interstitial  myoma.  The  uterine  cavity  was  also  greatly  increased  in  .size, 
being  31  cm.  long,  and  varying  from  9  to  14  cm.  in  diameter.  The  mucosa  was 
naturally  greatly  thinned  out.  About  the  middle  of  the  cavity  were  delicate 
papillary  outgrowths  from  the  surface  epithelium. 


THE    COXDITIOX    OF   THE    UTERINE    MUCOSA    IX    CASES    OF   MYOMA.  333 

In  Case  3340  (Path.  No.  GOT)  the  uterus  was  the  seat  of  subperitoneal,  inter- 
stitial, and  suhnuu'ous  niyomata  and  the  uterine  cavity  was  (i  em.  long.  The 
mucosa  was  somewhat  atro]:)hic.  The  surface  e))itlielium  was  everywhere  intact, 
and  in  most  places  normal,  ))ut  near  the  submucous  myomata  were  three  finger- 
Hke  outgrowths  of  epithelium,  and  not  far  distant  from  these  the  surface  ej)ithe- 
lium  had  proliferated,  being  three  or  four  layers  in  thickness.  The  newly  formed 
cells  stained  much  more  faintly  than  normal  epithelial  cells,  and  they  were 
separated  from  each  other  by  a  moderate  number  of  polymorphonuclear  leuko- 
cytes.    The  uterine  glands  were  normal. 

Were  the  mucosa  lining  all  portions  of  the  uterine  cavity  systematically 
examined  histologically,  we  feel  sure  that  such  alterations  in  the  surface  epithe- 
lium as  we  have  noted  would  be  much  more  frequently  found.  Some  of  them 
undoubtedly  indicate  a  commencing  malignant  change;  others,  however,  would 
advance  no  further. 

Adenocarcinoma. 

This  subject  is  dealt  with  fully  on  ])]).  274  and  404. 

A  Small  Myoma  Developing  in  the  Uterine  Mucosa. 
Tn  Fig.  231  we  have  a  definite  example  of  a  small  myoma  originating  in  the 
uterine  mucosa.  It  is  the  only  picture  of  this  kind  that  we  have  ever  encountered . 
The  uterus  formed  a  glo])ular  tumor,  14  cm.  in  diameter.  The  anterior  wall 
contained  an  interstitial  and  slightly  submucous  myoma,  12  cm.  in  diameter. 
The  uterine  cavity  was  12  cm.  long,  1 1  cm.  in  l)readtli.     Its  mucosa  was  atroj)hic, 


Fk;.  '2'M. — A  Myoma  Oni(iiNATi\(;  in  thk   I'tkhink   Mrcosv.      iX  4  ilium.) 
Gyn.   No.  .5808.      Path.   No.   2101.      The  uterus  eoulaiueil   a  suli|>eriloiieal   and   irit<Mslitial   niy<iina.  an.!  two 
polypi  lay  in  the  uterine  cavity. 

The  muco.sa  at  a  and  a'  is  perfectly  normal,  e.xcept  for  slight  ulaml  dilatation,  hut  hetween  these  points  and 
projecting  slightly  from  the  surface  is  a  small  flat  myoma.  This  is  confineil  entirely  to  the  mucosa,  hivs  pushed  the 
glands  to  either  side,  and  is  covered  over  with  the  surfiice  epithelium,  h.  This  myoma  hail  undoulitedly  originated 
in  the  nuu-osa,  probably  from  some  preexisting  muscle-fibers  that  were  located  there.  In  the  lower  part  of  the 
picture  a  small  i)ortion  of  a  large  interstitial  myoma  is  seen. 

and  some  of  its  glands  were  dilated.  I'lojccting  into  its  ca\-ity  was  a  tongue- 
sha])ed  polyp,  3.5  cm.  long  and  !.;>  cm.  broail.  A  second  and  smaller  one  lay 
near  the  internal  os. 

On  histologic  examination  the  muco.sa,  aj)art  from  atroj)hy  and  gland  dilata- 
tion and  the  presence  of  the  myoma,  as  seen  in  Fig.  231,  was  little  altered. 


334 


MVo.MATA    OF    THH    ITKRUS. 


Endometritis. 

Inflaiiiinatioii  of  the  (■iKlonictriuni  has,  in  our  experience,  l)een  very  rare. 

One  of  us  (Ciillcn)  in  1898*  re])orte(l  that   in   tiie  routine   examination  of  the 

specimens  from  the  »z:}'necol()gic  o])eratinf2;-room  of  the  Johns  Hopkins  Hospital 

for  a  period  of  four  years  endometritis  had  been  found  only  48  times;  in  other 


Fig.  232. — Polypoid  Endometritis  and  Doubi.k  Pus-tibes  .\ssociatki)  with  a  Myoma  of  the  Fi'.s'dis. 

(t3  nat.  size.) 

Gyn.  No.  869.3.  Path.  No.  4898.  The  uterus  wa-s  pyriforin  in  shape,  and  iiieasureil  1 1  x  7  x  (>  cm.  In  the 
fundus  wa-s  a  myoma  5  cm.  in  diameter.  The  uterine  mucosa  varied  from  2  to  4  mm.  in  thickness,  and  presented 
a  granular  appearance,  due  to  flattened  projections  varying  from  1  to  1 .5  mm.  in  diameter.  The  tubes  and  ovaries 
were  bound  up  in  a<lhe.sions.  Both  tubes  were  filled  with  pu.s.  On  histologic  examination  it  was  found  that  the 
surface  of  the  mucosa  was  in  many  places  greatly  altered,  the  cylindric  epithelium  having  been  replaced  by  many 
layers  of  cells  resembling  squamous  epithelium.  Lying  beneath  the  epithelial  cells  were  myriads  of  polymorpho- 
nuclear leukocytes.  The  knob-like  outgrowths  were  composed  of  newly  formed  connective  tissue  containing 
many  blood-vessels,  and  covered  externally  with  cylindric  epithelium  or  with  many  layers  of  cells  of  the  squamous 
type.  The  uterine  glands  showed  some  hypertrophv-  in  the  superficial  portions,  but  in  the  depth  most  of  them 
were  normal. 


words,  on  an  averajie  of  only  once  each  month.  \\r  were  astonished  at  the  lack 
of  fre(iuency  with  which  it  was  encountered,  and  were  still  further  surj)ri.sed  to 
find  that  even  when  the  I'alloiiian  tuhes  sho\\('(l  dcliiiitc  (■\-ideiices  of  inflamma- 
tion, the  endometrium  was  often  unaltered.  If.  however,  an  inflammation  of 
the  uterine  muccsa  exists,  the  excessive  vascularity,  together  with  the  excellent 
*  Thomas  S.  CuUen,  Endometritis,  Md.  Med.  J.,  189S,  p.  r^7l. 


THE    COXDITIOX    OF   THE    UTERIXE    MUCOSA    IX    CASES    OF    MYOMA.  335 

drainage  afforded  1)}'  the  more  or  less  perpendicular  position  of  the  uterus,  favors 
the  speedy  restoration  to  normal. 

What  applies  to  the  endometrium  in  general  is  equalh'  applicable  in  myoma 
cases.  In  our  experience  the  mucosa  rarely  shows  any  inflammation  when  the 
uterus  contains  myomata.  After  carefully  tabulating  the  cases  in  which  there 
was  an  endometritis, — usually  of  a  very  mild  grade, — we  have  found  that  \A-ith 
one  or  two  exceptions  either  the  uterus  contained  a  submucous  mj'oma,  usually 
disintegrating,  or  the  tul)es  showed  definite  evidences  of  a  recent  or  old  inflam- 
mation. 

These  findings  are  of  importance  to  the  surgeon  in  that  he  can  with  alnujst 
certainty  say  that  if  the  patient  has  no  vaginal  discharge,  and  if  the  appendages 
are  normal,  the  uterine  mucosa  is  unaltered.  Knowing  this,  he  can  open  the 
uterine  cavity,  if  necessary,  with  relative  certainty  that  there  is  no  danger  of 
infection  lurking  there. 

In  Fig.  232  we  have  an  examj^le  of  a  small  myomatous  uterus  with  a  fine 
]X)lypoi(l  endometritis,  associated  with  double  pus-tubes. 


Tuberculosis  of  the  Endometrium  Associated  with  Uterine  Myomata. 

From  the  accompanying  table  it  will  be  seen  that  we  have  had  7  cases*  in 
which,  in  addition  to  the  myoma,  tuberculosis  of  the  endometrium  was  noted. 
In  6  of  the  cases  the  uterus  was  relatively  small:  only  in  Case  3319  did  it  reach 
fairly  large  proportions.  In  2  of  the  cases  minute  tubercles  were  recognized  on 
the  surface  of  the  uterus. 

In  some  of  the  cases  the  implication  of  the  endometrium  was  quite  recent;  in 
others,  nearly  the  entire  mucosa  had  been  replaced  by  tuberculous  tissue,  and  in 
Case  4965  the  small  uterine  cavity  was  filled  with  creamy  fluid. 

In  Case  3319  the  tuberculosis  had  extended  to  the  muscle  l)eneath  the  mu- 
cosa. In  none  of  our  cases,  however,  had  the  tuberculous  ])rocess  involved  a 
myoma.  In  April,  1901,  Dr.  Homer  (Jage,  of  \\'orcester,  Mass.,  sent  us  a  myo- 
matous uterus  showing  definite  tuberculous  implication  of  a  myoma.  The 
interstitial  myoma  was  ap])roximately  globular  and  7  cm.  in  diameter.  On 
section,  it  ])resented  a  i)utty-like  appearance  and  was  very  soft,  fully  three- 
fourths  of  the  myoma  showing  this  degeneration.  Snieai's  made  by  Dr.  ( lage 
yielded  tubercle  bacilli  in  moderate  numb''i-s. 

On  making  sections  from  the  eiidoniet  riuni  we  found  nonn;il  imieosa  in  ])laces, 
but  at  other  points  the  stroma  showed  small- lound-cel led  inliliialion,  and  at  one 
point  in  the  mucosa  a  definite  tubercle  was  found. 

The  myoma  was  everywhere  riddled  with  areas  of  caseation  showing  sur- 
I'ounding  zones  of  tubcTculous  tissue.  All  stages  in  the  tui)ereulous  ])rocess 
were  demonstrable.  Scattered  throughout  the  myoma  were  a  few  islands  of 
uterine  mucosa.     In  other  words,  it  was  in  pai1  an  interstitial  adeiioniyoma. 

*  The  ciidometrium  was  also  tubcirulous  in  Aut.  Xo.  SO'J  (Path.  No.  1382). 


336 


MYOMATA    OF   THE    UTERI'S. 


Both  tubes  wciv  tlu'  scat  of  advanced  tulx'i'ciilosis.  , 

It  is  well  known  that  tiil)ereulosis  of  the  tubes  is  usually  ])resent  when  tuber- 
culosis of  the  endometrium  is  found,  and,  as  seen  from  the  table,  our  cases  closely 


Fig.  2.3.3. — TrBERCULOSis  of  the  Endometrium  and  Fallopian  Tubes  Associated  with  a  Myomatous  Uterus. 

(V  nat.  .size.) 
Gyn.  No.  3319.     Path.  No.  592.     The  myomatous  uteru.s  mea,sured  15  x  17  ,x  20  cm.     Situated  in  the  posterior 
wall  is  a  large  myoma;  in  the  anterior  wall,  a  second;   while   just   posterior  to  the  cervi.x  is  a  third.    The  endome- 
trium is  roughened,  as  indicated  by  a.     This  is  due  to  a  loss  of  substance  caused  by  the  tuberculosis.     The  left 
tube  is  thickened  and  tuberculous.     The  left  ovary  contains  a  corpus-luteum  cyst. 

follow  this  rule.     In  five,  both  tubes  were  involved:  in  a  sixth  ease,  one  tube. 
In  only  one  ease  was  there  no  e\'ideii('e  of  tubal  tuberculosis. 

The  a.ssociation  of  tuberculosis  of  the  endometrium   with  uterine  myomata 
must  be  regarded  as  a  mere  coincidence. 


TUBERCULOSIS  OF  THE  ENDOMETRIUM  ASSOCIATED  WITH  UTERINE  MYOMATA. 


Gyn.  No. 

Path.  No. 

Size  of  Uterus. 

Conditions  of  Tubes. 

Endometrium. 

3319 

592 

15  X  17x20  cm.  (Fig.  233). 

Tuberculosis  of  both 

tuljcs. 

Advanced  tuberculo- 
sis. Commencing 
involvement  of  un- 
derlying nuisde. 

496.5 

1499 

4  x  3.8  X  3    cm.       Largest 

Hotii     tui)es        em- 

Early   tul)erculo.si.s   of 

myoma  on  surface,  5  cm. 

bedtled    in    adhe- 

endom(>trium. 

Cavity  small,  filled  with 

sions,  but  not  tu- 

creamy  fluid. 

IxTcuious. 

6991 

3277 

6  X  6.5  x6  cm.      .Mimite  tu- 

Tul)erculosis of  one 

Early    tuberculosis    of 

bercles  over  surface 

tube. 

endometrium. 

8220 

4403 

Slightly  enlarged. 

Tuberculosis  of  botli 
tubes. 

I'^arly  tuberculosis  of 
endometrium. 

9636 

5825 

Myoma,  8  cm.,  in  posterifjr 

Tuberculosis  of  both 

Early    tuberculosis   of 

wall. 

tubes. 

endometrium. 

12119 

8714 

7x8x7  cm.     Several  my- 

Tul)erculosisof l)otli 

Tuberculosis      of    en- 

omata  from  surface;  lar- 

tubes. 

ilometrium. 

gest,     14  X  11  X  11     cm.; 

minute  tubercles  on  sur- 

face. 

12860 

97.55 

7x8x8  cm. 

Tul)ercul()sis  of  both 
tubes. 

Tuberculosis  of  endo- 
metrium. 

CHAPTER    XVIII. 

CONDITIONS  OF   THE   TUBES   AND  OVARIES  WHEN  UTERINE 
MYOMATA  ARE  PRESENT,  =^= 

Although  our  investigations  arc  based  on  over  1400  cases  coming  under  oiu' 
observation,  many  of  the  cases  operated  upon  in  the  smaller  hospitals  could  not 
be  as  carefully  tabulated  from  a  clinical  and  ])athologic  standpoint  as  were  those 
observed  in  the  Johns  Hopkins  Hospital.  (  onsecjuently,  in  discussing  the  con- 
dition of  the  tubes  and  ovaries,  we  have  utihzed  only  those  cases  admitted  to 
this  institution. 

A  SUMMARY  OF  THE  CONDITION  OF  THE  TUBES  IN  934  CASES  OF  UTERINE  MYOMA 
WHERE  IT  WAS  NECESSARY  TO  REMOVE  THE  UTERUS. 

Free  from  adhesions 511  cases 

Free  from  adhesions,  but  showing  some  other  pathologic  change 29     " 

Total  number  in  which  normal  tubes  were  present 482  cases 

Adhesions. 

Both  tubes  adherent 364  cases 

One  tube  adherent 59     " 

Total  number  in  which  one  or  both  tubes  were  adherent 423  cases 

Dense  tubal  adhesions  were  present  in 94  of  these  cases 


Hydrosalpinx 88  cases: 


Hematosalpinx 12  cases: 

^,        ■        1   •      •,.  ,o  /  43  bilateral. 

Chronic  salpmgitis 48  cases:  <      -       •■   .       i 

'     ^  I     •»  unilateral. 

/   19  unilateral. 

\  22  bilateral. 

/   1  right  side. 

\  4  left  side. 

n^  ,              •       i.          ij  r  f  3  riglit  side, 

lubo-ovarian     mass    5  cases:  <    .,  •  ?,    ,•  • 

f  4  right  sitle. 

Tubo-ovarian  abscess 14  cases:  -i   9  left  side. 

[  1  bilateral. 

Tubercidosis 14  cases:  both  tubes  involved. 


Q.       ,  „„   r  51  unilateral. 

^™P^« ''   \  26  bilateral. 

n,  ,,•     1  in  f  6  unilateral. 

F°ll'^^'l^^»- ^S  4  bilateral. 

1  pn^P  ^  "S'lt,  follicular. 

^  '^'^^^  \  left,  simple. 
/  9  unilateral. 
\  3  bilateral. 


Pyosalpinx 41  cases: 

Tubo-ovarian  cyst 5  cases: 


Tul)al  ))regnancy 6  cases: 


/  5  ruptured. 
\   1  intact. 


Rudimentary  left  tube,  1  case  (Oyn.  No.  10917). 
Myoma  of  the  tube.  1  case  ((lyn.  No.  10237). 

*  In  the  tabulation  of  the  condition  of  the  tubes  and  ovaries  we  have  exerci.sed  great  care, 
but  as  in  some  cases  one  or  both  appendages  were  not  removed,  and  only  a  con.servative  opera- 
tion was  performed,  we  have  occasionally  been  compelled  to  rely  entirely  on  the  notes  made  at 
operation.  In  some  cases  these  are  naturally  incomplete.  Accordingly,  it  will  Ix' safer  to  make 
an  allowance  for  possible  error  in  the  statistics  of  about  1  per  cent. 
22  337 


338 


:\IYOMATA    OF   THE    UTERUS. 


Adherent  Tubes.  -From  tlie  suinmary  it  is  seen  that  one  or  both  tiihcs  were 
adherent  in  42;j  out  of  934  cases.  This  is  a  hirge  percentage.  In  many  of  the 
cases  the  adhesions  were  shght;  in  others  sufficient  to  occlude  the  tu])e  and  j^ro- 
duce  a  hyth-osalpinx,  while  in  a  good  many  cases  the  tu])es  were  densely  adheicnt 
as  a  result  of  a  pyo.salpinx  or  pelvic  abscess. 

The  friction  between  the  tumor  and  the  pelvic  ix'ritoneum  naturally  tends  to 
cause  irritation  of  the  .surfaces,  with  the  occasional  formation  of  .shght  adhesions. 
Again,  the  myomata,  as  they  grow,  may  ])artially  l)l()ck  the  uterine  cavity  and 
force  the  uterine  secretions  or  menstrual  How  out  through  the  tubes.  A  mild 
inflammation  may  thus  be  set  up.      Sloughing  submucous  myomata  also  are 

resi)onsibh'  for  infhunmatory  changes. 
In  other  cases  the  infection  is  im- 
(loul)ledly  introduced  from  without. 

Being  at  a  loss  to  explain  the 
large  [percentage  of  cases  in  which 
adhesions  existed,  the  histories  were 
carefully  examined  to  see  how  many 
patients  were  colored,  as  the  per- 
centage of  tubal  lesions  is  known  to 
be  much  larger  in  the  negress: 

Total  luunljer  of  whites 60<S 

Adherent  appendages  in  216  cases  (.35.0  per 
cent.). 

Total  number  of  colored 326 

Adherent   appendages    in   207   cases  (6.3  per 
cent.). 

The  result  shows  tliat  in  the  colored 
adherent  ajjpendages  were  nearly 
twice  as  fre(nient  as  in  the  white 
women. 

Hydrosalpinx. — Hydrosali)inx  was 
noteil  ill  SS  of  the  ca.ses.  In  77  of 
these  it  was  of  the  simj)le  variety; 
in  11,  follicular  hydrosalpinx  was 
present.  A  very  mild  grade  of  inflammation  is  often  sufficient  to  occlude  the 
fimbriated  end  of  the  tube,  and  a  hydrosalpinx  is  the  natural  secjuence.  We 
have  frecpiently  .seen  the  occluded  tube  lying  free  in  the  pelvis,  being  nowhere 
adherent. 

Hematosalpinx. — In  12  cases  a  hemato.salpinx  was  noted.  As  a  rule,  a  hema- 
tosalpinx is  a  hydro.salpinx  into  which  a  hemorrhage  has  taken  place.  If  we 
include  these  two  varieties,  in  one  grou])  we  have  100  cases  out  of  934  showing  a 
non-))urulent  accumulation  of  fluid  in  the  Fall()])ian  tube. 

Salpingitis.  Salpingitis  and  pyosalpinx  have  been  emi)loye(l  really  as  synony- 
mous terms.     In  our  cases  the  inflammatorv  changes  in  the  tubes  in  the  main 


Fic.  234. — A  Myomatous  Uterus  .-V.s.sociated  with 
Pyosalpinx. 
(iyn.  No.  6381.  The  omentum  \va.<  adherent  to  the 
abdominal  wall  and  bladder.  Situated  in  the  anterior 
uterine  wall,  and  lying  partially  beneath  the  bladder,  is 
a  myoma  several  centimeters  in  diameter.  In  the  pos- 
terior wall  is  a  smaller  one.  Lying  behind  the  uterus  and 
adherent  to  it  is  the  right  tube,  which  is  distended  with 
pus.  n  reached  2.5  cm.  in  diameter.  The  left  tube 
also  contained  a  purulent  accumulation. 


CONDITIONS    OF    THK    TIHKS    AM)    ()\ARIES. 


339 


were  chronic  at  the  time  of  ojx'i-atioii.     \Mien  the  tube  was  small,  hard,  and  in- 
durated,  we   usually   term(Nl    the   condition   a  salpin.uitis,  hut    when   enlarged, 


Fig.   2.35. — A  Tuho-ovariax  Cyst  Associated  with  a   Myomatous  Uterus.     (j\  nat.  size.) 
San.  No.  2368.     Path.  No.  11191.     The  large  myomatous  uterus  is  pear-shaped,  and  projecting  from  its  sur- 
face is  a  small  pedunculated  myoma.     The  right  tube  is  occluded  and  is  the  seat  of  a  hydrosalpinx,    a  is  a  corpus 
luteum.     The  left  tube,  for  the  most  part,  is  normal.     The  outer  end,  however,    is  distended  and  lobulated;  it 
communicates  with  the  ovarian  cyst.     The  fluid  filling  the  tube  and  cyst  was  clear  and  limpid. 


Fig.  2.36. — A  Tuho-ovarian  Cvst  and  Dense  Adhesions  Co.mpi.icatinc  a  Myomatous  I'tekus.  (5  nat.  size.) 
San.  No.  S.'xS.  I'ath.  No.  3706.  I'lilly  one-half  of  the  posterior  surface  of  the  uterus  \va.s  covered  with  ilense 
adhesions.  The  uterus  contained  a  inyiiina,  .5. .5  cm.  in  diameter.  The  left  tulie  and  ovary  were  somewhat  ad- 
herent, but  the  fimbriated  end  of  the  tube  was  initent.  The  rlglit  tulie  in  its  outer  i)(>rtion  wa.s  nuich  dilated,  and 
at  its  outer  end  reached  5  cm.  in  diameter.  The  longitudiiuil  ridges  on  its  inner  surface  indicate  the  tubal  folds. 
The  ovary  had  been  converted  into  a  simple  cyst  which  mea.'<ure<l  7  cm.  in  diameter.  The  <lilated  tube  and  the  cyst 
communicate  at  a.  Both  were  lilleil  with  clciir  llui.l.  I  li-tnli.;;ic  exaiiiiiiatioM  nf  ilic  cNst  indicated  that  it  was 
a  dilated  Graafian  follicle. 


hard,  and  filled  with  an  apprcciahlc  (|uantity  of  pus.  we  put  it  down  as  a  pus-tuhe 
(Fig.  X\\)  or  a  pyo.salpiux. 

In  4<S  cases  salpingitis  was  found,  and  it  is  iiUci-csiing  to  note  that   in  4.")  out 
of  the  48  the  condition  was  liilatcral. 


340 


MYo.MATA    OF    TllK    ITHIUS. 


In  41  cases  pyosaljjiiix  was  found.  Thus,  in  89  out  of  the  934  cases  a  definite 
inflammatory  process  existed  in  one  or  both  tubes. 

It  is  very  difficult  to  discuss  i)urulent  chan,ii;es  in  the  tubes  without  the  coin- 
cident consithM'ation  of  infianunatory  lesions  in  the  ovaries  so  intimately  associ- 
ated with  them. 

In  ")  cases  "  tul)0-ovarian  masses"  were  found.  This  clinical  term  indicates 
a  firm  inflannnatory  mass  without  macroscojiic  evidence  of  pus.  In  14  other 
cases  tubo-ovarian  abscesses  were  ])resent.  It  will  thus  b(>  seen  that  in  over 
10  j)er  cent,  of  the  cases  the  a|)])endages  wei-e  the  seat  of  ))urulent  changes. 
In  such  cases  the  ])atient  had  usually  suffered  more  pain  than  falls  to  the 
lot  of  one  affected  with  a  simple  myoma.  Moreover,  the  operative  measm'es 
required  are  naturally  more  radical,  and  at  the  same  time  more  difhcult, 
than  th(\v  would  be  if  the  aj)i)endages  were  free  from  adhesions. 

The  same  factors 
that  produce  hydrosal- 
pinx cause  pyosalpinx, 
the  only  difference  being 
tliat  in  the  latter  the 
inflammatory  reaction  is 
more  se^'ere. 

Tubo-ovarian  Cysts. 
— In  5  cases  of  our 
series  tubo-ovarian  cysts 
were  found.  In  these 
cases  the  tube  is  the 
seat  of  a  hydrosalpinx 
and  is  intimately 
blended  with  the  ovar}-, 
which  is  usually  con- 
verted into  a  single  cyst. 
On  section,  it  is  found  that  the  distended  tube  connnunicates  by  a  large  or 
small  opening  with  the  ovarian  cyst.  The  fluid  filling  the  cavities  is  usually 
clear  and  limpid.  In  these  cases  there  has  evidently  been  a  mild  inflammation; 
the  tube  has  become  glued  to  the  ovary,  and  a  hy(lr()sali)inx  has  developed. 
At  a  later  date  a  matured  Graafian  follicle  at  the  point  of  adhesions  has  been 
unable  to  empty  itself,  and  has  developetl  into  a  (Jraafian  follicle  cyst.  The 
cyst  and  the  hydrosalpinx  have  eventually  opened  into  one  another.*  In  Fig. 
235  we  have  a  very  good  example  of  a  tubo-ovarian  cyst  associated  with  a 
myomatous  uterus.  Fig.  236  shows  a  somewhat  similar  tubo-ovarian  cyst  on 
section. 

A  Rudimentary  Fallopian  Tube. — In  Gyn.  No.  10917  the  omentum  was 
firmly  adherent  to  the  uterus,  which  contained  several  small  myomata.     The 

*  Thoma.s  S.  Cullen,  Hydrosalpinx.  .lolins  Hopkins  Reports.  1S9.5,  Vol.  4. 


Fig.  237. — A  Mvoma  of  the  Right  F.\llopi.\n  Tube,     (i  nat.  size.) 
Gyn.   No.   10237.     Path.   No.    6430.     To  the   right  was    a  parovarian 
cyst,  20  cm.  in  diameter;  to  the  left,    an   ovary   containing   several    large 
cystic  follicles. 

Springing  from  the  anterior  surface  of  the  uterus  near  the  left 
round  ligament  is  a  small  pedunculated  myoma.  The  uterine  cavity  is 
almost  completely  filled  with  polypi.  Projecting  from  the  upper  surface 
of  the  right  tube  at  a  is  a  pedunculated  myoma,  which  measured  7  x  8  x 
10  mm. 


COXDITIO.XS    OF    THE    TrBp:S    AXD    OVARIES. 


341 


right  tube  and  ovary  wc^rc  iionnal.  Tlic  left  ovary  was  ahsont,  and  llic  left  lul)0 
was  represented  l)y  a  mere  remnant  of  a  noi'nial  tulx".  It  had  evidentlv  never 
fully  d(>vel()i)ed. 

Myoma  of  the  Fallopian  Tube. — The  tul)al  muscle  is  similar  to  tliat  of  tlie 
uterus,  and  as  myoniata  are  so  eonnnon  in  the  uterus,  we  would  consequently 
not  be  surprised  if,  at  times,  myoniata  should  develop  from  the  tube. 

Case  10237  is,  however,  the  only  one  in  which  any  tendency  toward  a  tubal 
myoma  was  found.  In  this  case  the  patient  was  seventy  years  of  age.  The  uterus 
measured  2.5x3  x()  cm.,  had  a  small  {)edun('ulated  myoma  springing  from  its 
outer  surface,  and  contained  several  polypi.  On  the  right  side  was  a  parovarian 
cyst,  20  cm.  in  diameter.  On  the  left,  the  ovary  measured  3x3.5x6  cm.,  the 
increase  in  size  being  caused 
by  several  umisually  large 
Graafian  follicles.  Arising 
from  the  upper  surface  of 
the  light  tube  near  the 
uterus  was  a  well-defined 
myoma,  7  x  8  x  10  nun. 
(Fig.  237). 

Tuberculosis  of  the  Fal- 
lopian Tubes. — In  14*  of 
the  934  cases  the  Fallopian 
tubes  were  the  seat  of  tu- 
berculosis, and  in  all  these 
cases  the  disease  was  bilat- 
eral. In  6  of  the  cases  the 
tuberculous  character  of  the 
process  was  recognized  only 
on  microscopic  examination. 

Ill  2  of  the  6  a  distinct  infiammatory  process  was  preseiil,  but  no  lubei-cles 
were  detected  maeroscopically.  and  in  another  of  the  cases  (1142S),  although  a 
tubo-ovarian  abscess  was  present  on  the  left  side,  no  macroscopic  evidence  of 
tuberculosis  was  found.  In  the  remaining  7  cases  tubercles  were  e\ideiit, 
and  the  cHagnosis  was   readily  established  when  the  abdomen  was  opened. 

The  presence  of  a  thickened  nodular  tub(>  with  a  patent  (inibriated  exti-eiiiity 
is  always  strong  pi'esumi)tive  evidence  of  tubei'culosis  in  this  situation. 

In  Case  4732  there  was  a  wide-sj)read  tuberculous  jx'ritonitis. 

Fi'om  the  (Tmical  histories  it  is  eN'ident  that  in  only  one  of  the  II  cases  would 
the  ])hysician  ha\'e  suspected  tubercailosis  prioi-  to  oix'i'alion.  the  symptoms  of 
th(>  myoma  in  each  case  ox'ersliadowing  those  of  the  tuberculosis.  The  e\ce])tion 
was  Case  12866.     This  patient,  three  years  ])re\i()usly,  had    been    admitted  to 

*(;yn.  Nos.  ;«li»,  K)22,  17;52.  (l!»i)l,  7J41,  S22().  <)():5(i.  '.».S'J3.  lOlTJ.  1():>S7,  1  1  IJS,  117(W, 
1211!),  12><(ifi. 


C  e  r  V 
Fig.  238. — Ruptured  Tubal  Prkgnancy  Complicating  Uterine 
MyoMAT.\.  (S  nat.  size.) 
(iyn.  No.  8985.  Path.  No.  5159.  The  uterus  is  iiioderatel.v 
enlarged,  owing  to  the  presence  of  several  myomata.  The  left  tube 
was  adherent.  The  right  ovary  aj^pears  normal,  but  the  tube  near 
its  middle  is  considerably  dilated,  and  at  a  placental  tissue  and 
clotted  blf)oil  project  through  a  rent  in  the  aniciidr  wall. 


342 


.MVOMATA    OF   THK    ITKIUS. 


Dr.  Halstt'd'.s  service  suffei-iiiji;  from  tiilierculosis  of  the  hip.  \\'heii  she  entered 
the  gynecological  dcpartiiK'Hl  there  weiv  definite  signs  of  tuberculosis  of  the  right 
kidney,  the  right  ureter,  anil  of  an  early  tuberculosis  of  the  bladder.  The  ])ains 
in  the  right  iliac  fossa  naturally  suggested  the  possible  development  of  an  early 
tuberculous  ])rocess  in  this  location.  Thus  in  13  out  of  14  ca.ses  in  which  tuber- 
culosis of  the  tubes  was  associated  with  uterine  myomata,  the  chie  as  to  the 
tubal  complication  clinically  was  absolutely  wanting. 

In  some  of  the  cases  examination  of  the  eiidoiiietrium  would  have  shown 
tuberculosis,  as  evidenced  by  the  .subsequent  pathologic  findings,  but,  as  a  rule, 
the  operator  refrains  from  cuivtting  v/hen  the  diagnosis  of  myoma  is  perfectly 
clear. 

Tubal  Pregnancy. — In  O.'U  of  our  ca.ses  6  tubal  pregnancies  were  detected. 
P'rom  the  accompanying  table  it  will  be  seen  that  ">  were  ru))ture(l  and  1  was 
intact. 

The  left  tube  in  Case  12380  .showed  a  globular  thickening,  4  em.  in  diameter, 
near  the  uterus,  but  the  fimbriated  end  was  intact.  \\'hen  the  tul)e  was  opened, 
the  tyjjieal  picture  of  tul)al  {)regnancy  was  noted. 

TABLE  OF  TUBAL  PREGNANCIES  ASSOCIATED  WITH  UTERINE  MYOMATA. 


Gyx.  No. 


Nu.MBER  OF 

Ye.^rs  Number  ok 

Married.  Children. 


7795 
7849 
8985 
8990 


924:i 
12380 


5 
10 
10 
12  (col) 


11 


14 


0 

0 

0 

1 
(twenty-one 
years  ago). 

0 

0 


Number 
of  Mis- 
carriages. 


Symptoms  Suggesting 
TuB.\L  Pregn.^ncy. 


Of  no  value. 
Of  no  value. 
Of  no  value. 
Definite  .'^ign.s  of  prej 
nancy. 

Of  little  value. 


R.  or  L.  Tub.  Preg. 
Intact  or  Ruptured. 


R.,  rupt. 

L.,  partly  ruptured. 
R.,  rupt  (Fig.  238). 
L.,  five    months    rup- 
tured. 


'  R.,     rupt.     (niyoMiec- 
tomy). 
History  slightly  sug-    L.,       ruptured       (.see 
gestive     ("velvety  "Adenomyoma       of 

feel").  the     I'terus,"     Fig. 

,     66,  p.  247). 
I 


This  table  shows  that  5  of  the  6  ])atients  had  never  l)een  delivered  of  a  child 
at  term,  and  3  of  the  6  had  never  been  pregnant  before. 

From  a  clinical  stan(l])()int  it  is  interesting  to  note  that  in  4  of  the  eases  the 
sym))toms  attributable  to  tlie  myoma  completely  overshadowed  those  of  the 
tubal  pregnancy.  Conseciuently  the  surgeon  was  totally  unaware  of  the  condi- 
tion imtil  the  abdomen  was  o])ene(l. 

In  Case  123S()  the  uterus  was  the  .seat  of  .several  myomatous  notlules,  and  a 
hrm  tumor  was  felt  to  the  left  of  the  uterus.  This,  on  pali»atioii,  difi'ered  ma- 
terially from  the  myoniata.  On  gentle  ])ali)ati()n  it  felt  soft,  but  when  firm 
pressure  was  exerted,  hard.     It  reminded  one  of  a  hai'd  ball  covered  with  velvet.* 

♦Thomas  S.  Cu Hen,  The  Velvety  Feel  of  an  Unrui)tur(Ml  rul)al  Pregnancy,  Johns  Hopkins 
Hosp.  Bull.,  1906.  p.  1.54. 

See  Cullen,  Adenomyoina  of  the  Uterus,  Fig.  66,  p.  247,  W.  B.  Savuiders  Co.,  19t)8. 


COXDITIOXS    OF    THI-:    TURKS    AXI)    r)VAI{IF-:S. 


343 


The  soft  feel  was  due  to  the  ])r(\mi;uit  sphere  heiii^'  surrounded  by  soft  tubal 
muscle  and  numerous  dilated  bIo()d-\'essels.  This  sifjn  is  natui-ally  obsciu'cd  if 
the  tube  mptures. 

Mechanical  Alterations  in  the  Tubal  Relations. — In  the  majority  of  the  cases 
in  which  no  infianunatory  clian<2;es  in  the  appendages  are  present  the  tubes  pre- 
sent a  normal  a))pearance.     When  the  myoma  extends  far  out  into  the  l)road 


_^ ^^  ;i-V 

Ut, cavity 

Fig.  239. — The  Median  End  of  a  Fallopian  Tuuk  Apparently  Terminating  in  a  Myoma.  (S  nat.  size.) 
Gyn.  No.  7063.  Path.  No.  3354.  Scattered  throughout  the  uterus  were  subperitoneal  and  interstitial  my- 
omata.  The  right  tube  and  ovary  were  covered  with  a  few  delicate  adhesions,  but  were  practically  normal.  The 
left  tube  looked  normal,  but  at  the  median  end  it  apparently  passed  directly  into  the  myoma.  Even  in  serial 
sections  it  was  impossible  Ui  trace  (he  tube  after  it  reached  the  myoma. 

ligament,  the  tube  may  be  greatly  stretched,  reaching  17  cm.  or  more  in  length. 
Occasionally  a  greatly  elongated  tube  may  be  associated  wilh  a  large  oxary,  as 
in  Fig.  245  (p.  351). 

I'ig.  231)  represents  a  multinodulai'  utei'us  with  a  large  nodule  projecting 
directly  Uj)ward  from  the  left  coi'iui.  The  left  tube  is  normal,  but  a]ii)arently 
passes  directly  into  the  myoma. 


CONDITION  OF  THE  OVARIES  IN  CASES  OF  UTERINE  MYOMATA. 

I'Vom  the  tabulation  we  found  that  in  the  (l.'!l  c.'ises  the  o\ai'ies  were  normal 
in  43S.  In  the  remainder,  comprising  oxci'  h;df,  I  he  o\"ai'ies  were  either  a dhei'eiit 
or  showed  some  pathologic  lesion. 


344  MVOMATA    OF    THK    UTKRUS. 

Free  from  ailhesions 508  cases 

Free  from  adhesions,  but  showing  some  pathologic  changes 70 

Both  ovaries  normal -138  cases 

Adhesions. 

Both  ovaries  adherent 370  cases 

One  ovary  adherent 56 

Total  iiuinhcr  in  which  one  or  i)oth  ovaries  were  adherent 426  cases 

In  05  of  these  cases  the  adhesions  were  dense.     (For  ovarian  abscess  and  tiibo- 
ovarian  abscess  see  tabulation  of  diseases  of  the  tubes,  p.  337.) 

Ovarian  abscess  a])])arently  not  associated  with  ])yosalpinx,  6  cases.  Pelvic 
pci'itonitis  with  abscess  formation  apparently  independent  of  ])yosali)inx  or  def- 
inite ovarian  abscess,  6  cases.     Tiil)erculosis,  3  cases  (tubes  |)i-iniarily  involved). 

Cysts. 

,,  .  .     1       •£•    1  II  /   37  unilateral. 

Mnall  ovarian  cvsts  not  classined 44  cases:   {      _  ,  .,  , 

\      I  l)ilateral. 

,.  ,,.  ,  ,  ro  i  .")6  unilateral. 

Graafian  iolhcle  cvsts 68  cases:  <       ,  ,  .,  , 

>.   12  bilateral. 

,.  ,  „ ,  r  32  unilateral. 

Corpus  luteum  cvsts 34  cases:  < 

12  bilateral. 

Multilocular  cystadenomata 9  cases 

„      .,,  ,  1.-,  j    10  unilateral. 

PapiUocystomata 12  cases:  < 

^        -^  I     •_'  l)dateral. 

Adenocarcinoma  (primary) 8  cases 

Dermoid  cyst 17 

Fibromata 3 

Very  large  ovaries 2 

Merging  of  a  myoma  and  an  ovary 1  case 

„  .  ,  io  f   IS  unilateral. 

Parovarian  cyst 19  cases:  \      ^  ,  ., 

•'  I      1  bilateral. 

Tubo-ovarian  abscesses  and  ovarian  abscesses  are,  for  obvious  reasons,  con- 
sidered with  inflannnatory  conditions  of  the  tubes. 

In  6  case.s*  there  was  an  ovarian  abscess  apparently  not  acconij)anied  by  a 
pyosaljjinx.     In  each  case  tiic  abscess  was  unilatei'al. 

Pelvic  ])eritonitis  with  ab.scess  formation  apparently  independent  of  any 
tubal  or  ovarian  ab.sce.ss  was  noted  in  5  cases.! 

In  184  cases  cysts  of  \-arious  sizes  were  noted.  ( )f  t  his  number,  44  wer(>  small, 
unclassified  ovarian  cysts;  68  Graafian  follicle  cysts;  34  corjnis  hiteum  cysts; 
9  multilocular  adenocystomata;  12  papillocystomata;  and  17  dermoid  cysts. 
In  addition  to  this  number  there  were  also  8  adenocarcinomata  of  the  ovary, 
nearly  all  of  which  were  cystic. 

Graafian  Follicle  Cysts.  We  know  that  ovarian  adhesions  tend  to  jM'event  the 
normal  cycle  of  the  (Iraafian  follicle,  and  as  the  ovaries  were  adherent  in  426  of 
the  934  cases,  it  is  but  natural  that    this  vaiiety  of  cyst  should   be  conmion. 

*  (lyn.  Xos.  2973,  3395,  5123,  5302,  9013,  12209. 
t  Gyn.  Xos.  .")010,  6199.  7320.  8008.  9678. 


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MVOMATA    OF    THK    i:Ti:iU'S. 


\A'c  tuuiid  ill  all  ()S  instances  of  Graafian  follicle  cysts.     The  smallest  was  2.5  cm. 
in  diameter,  the  largest,  22  cm. 

Corpus  Luteum  Cysts. — These  are  also  more  prone  to  occur  when  pelvic  ad- 
hesions exist.  They  wer(>  noted  in  34  of  the  934  cases.  The  smallest  was  2.5 
cm.  in  diameter,  the  largest,  3  x  5  x  10  cm. 

Multilocular  Cystadenomata. — In  9*  of  the  934  cases  mnltilocular  ovarian 
cvsts  were  found.  In  5  of  these  the  myoma  was  the  chief  factor.  In  the  re- 
maining 4  the  symptoms  caused  by  the  cyst  completely  overshadowed  those  duo 
to  the  myomata.  In  Case  7775  (Fig.  240),  the  myomatous  uterus  measured 
10x10x13  cm.,  the  cyst,  15x20x25  cm.  The  iiedicle  of  the  cyst  had 
formed  a  complete  rotation  from  right  to  left. 

When  the  cyst  is  relatively  small,  its  simultaneous  occurrence  with  the  myo- 
mata should  occasion  few  additional  symptoms, 
but  when  it  has  reached  large  ])ro portions  (Fig. 
241),  dense  adhesions  are  liable  to  give  rise  to 
very  serious  complications. 

Case  9030  affords  a  striking  example  of 
such  com])lications.  The  patient,  aged  fifty- 
one,  at  the  time  of  operation  was  very  weak  and 
anemic.  On  opening  the  abdomen,  in  addition 
to  the  myomatous  uterus,  20  cm.  in  diameter, 
we  found  the  abdomen  nearly  filled  with  a 
nuiltilocular  ovarian  cyst.  This  was  every- 
where very  adherent  to  the  intestines,  and  was 
tumor  which  extends  slightly  above  the     Separated    iu   nuuiy    placcs   by    Sacrificing    the 

umbilicus.      To  the  right  is  a  hematoma.  .  11  t^       •  -^  1      j.i  i. 

To  the  left  is  a  large  ovarian  cyst.  CVSt-Wall.       Dui'ing    itS     reillOVal     the    Cyst     ni\)- 

tured  and  a  large  amount  of  foul-smelling 
purulent  material  escaped.  This  was  at  once  carefully  wiped  out,  and  the 
myomatous  uterus  ciuiekly  removed.  At  the  end  of  the  operation  the  patient 
was  i)roioimdly  collapsed,  and  she  died  a  few  hours  later.  In  this  case  un- 
doubtedly the  multilocular  cyst  and  not  the  myoma  was  primarily  responsible 
for  the  patient's  death. 

Papillocystoma  of  the  Ovary. — In  12t  of  th(>  934  cases  i)apilloma  of  the  ovary 
was  associated  with  uterine  myomata.  In  10  of  the  cases  the  process  was  uni- 
lateral, in  2,  bilateral.  In  Case  10875  the  left  ovary  had  been  converted  into  a 
l)ai)illocystoma,  7  x  10  x  12  cm.  The  right  ovary  was  not  of  abnormal  size,  but 
histologic  examination  revealed  a  small  cystic  space  containing  a  j)aj)illomatous 
mass  in  this  ovary.     The  })rocess  here  was  an  excei)tionally  early  one. 

In  Cases  1455,  2172,  12034,  12912,  the  ])ai)illary  growth  had  penetrated  the 
cyst-wall  and  extended  to  the  peritoneum  of  the  .^surrounding  structures.  In 
Case  12034  there  was  also  fi'ee  ascitic  fluid  in  the  general  ju'ritoneal  cavity. 

*Gyn.  Nos.  6201,  7377.  777.3,  7971,  8227,  8266,  9030,  110.>0.  12764. 

tr.yn.  Nos.  14.1.-),  2172,  3898,  6344,  6439,  8738,  10867,  10875,  12034,  12848,  12849,  12912. 


Fig.  241. — A    Mi:ltipi,icity    ok    I'atho 
LOGIC  Conditions. 
Gyn.   No.  2172.     The  uterus  is  con 
verteJ  into    a    multinodular    myomatous 


CONDITIONS    OF   THE    TUBES    AXD    OVARIES. 


347 


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348 


MVO.MATA    OF    THK    ITKRUS. 


In  most  of  tlic  cases  tlic  inyoniata  were  ivlativcly  small,  and  dui-ini:;  the  few 
months  pi-i(ir  to  operation  the  syni])t()ms  referable  to  the  ])apillary  <:;r()\vth  ecinaled 
or  overshadowetl  those  of  the  myoniata. 

Tn  Case  (VMA  (Fii:;.  242),  however,  the  cyst  was  still  small,  and  the  lendeiiey 
towai'd  pai)illar_\-  foi'iiiation  markedly  limited. 

The  presence  of  i)apillary  masses  on  the  outer  surface  of  the  ovary  naturally 
handicaps  the  surgeon's  endeavors.  He  wishes  to  he  as  conservative  as  possible, 
but  realizes  that  where  one  ovary  is  extensively  involved,  the  opposite  one  is 
])rone  to  i)i('k  up  and  nurture  epithelial  cells  that  drop  off  from  the  pai)illary 
growth.  If  it  is  thought  that  the  opposite  ovary  is  still  normal  and  a  myomec- 
tomy is  contem])lated  in  the  ho])e  of  i)reserving  the  menstrual  function,  the 
surgeon  is  in  a  (juandary  as  to  whether  scattered  tumor-cells  may  not  engraft 
themselves  upon  the  uterus  at  the  point  from  which  the  myoma  has  been  shelled 
out.  Should  both  ovaries  be  involved,  however,  hysteromyomectomy  with 
complete  remo\al  of  the  appendages  is  clearly  indicated. 


ADENOCARCINOMA    OF   THE   OVARY    OCCURRING   WITH    UTERINE    MYOMATA. 


No. 


Utkrus. 


RiClIT    OVAHY. 


Left  Ovary. 


Path.  99  t'tcnis  contains  luunei- 
uus  myonuita.  the  largest 
4  X  4.r>\  .").")  em. 

(!yii.  11)37  .Moderately  small  myoma 
lo  left  of  cervix  not  re- 
nui\'eil. 

(Jyn.  10'_'()  Mullinixhilai-  myomatons 
uterus.  \'}\  19  \  21  cm. 


(lyn.  ').V2S  .Multinodular  myomatous 
uterus,  S  X  11  x  12  cm.: 
later  extension  of  ovarian 
carcinoma  to  body  of 
uterus. 

(Jyn.  (i479  Uterus  contains  .several 
myomata,  the  lariiest  '].r> 
cm. 

(lyn.  !)4.")7  Uterus,  9x11  cm.,  con- 
tains two  myomata.  the 
larger  S  x  9  cm.,  also  dis- 
crete adenomyoma. 

(lyn.  8G7.')  .Midlinoduhir  myomatous 
uterus,  6x  8x  11  cm. 
Largest  myoma,  3x5  cm. 


Cyn.  12011  Uterus  7xScin.  Several 
myomata,  the  largest 
1  cm. 


Springing  from  a  portion 
of  the  ovary  is  an  adeno- 
carcinomatouscyst  10  cm. 
in  diameter. 

Adenocarcinomatous  cyst 
contained  S.IOO  c.c.  of 
chocolate-colored  fluid. 
Adenocarcinoma  of  right 
ovary.  ,")..■)  x  (i  x  7..")  cm. 
Secondary  in\ol\cnient 
of  right  tube. 
Adenocarcinoma. 


Api)an'ntly      not       impli- 
cated. 

.-Adenocarcinomatous  cyst, 
20  cm.  in  diam. 


Contained  |)  a  p  i  1  1  a  r  y 
adenocarcinomatous  mass. 
1.5  cm.  in  il  i  a  m  e  t  e  r . 
Met  astases  in  omentum 
wide-spread. 


A    few    ]>apilltiry    masses. 
C  a  r  c  i  n  o  m  a  t  o  u  s     moss 
springing  from   slightly 
eidarged  ovary. 
Ovarv  normal. 


Multicystic  pai)illary  car- 
cinomatous masses  on  sur- 
face. 


Adenocarcinoma. 


Semisolid         adenocarcin- 
oma, 7  X  S  X  9  cm. 

Adhesions,  otiierwise  nor- 
mal. 


Two  ])etlunculated  hud- 
ding  papillomatous  masses 
on  upper  border;  adeno- 
carcinomatotis  on  histo- 
logic extimination. 
Adenocarcinomatous;  tvi- 
mor  small  and  den.sely 
adherent. 


Adenocarcinoma  of  the  Ovary, — In  <S  of  the  O.'U  cas(>s  adenocarcinoma  of  the 
ovary  was  present.  ^hicrosco})ically,  it  is  often  imjKJssible  to  distinguish  between 
papilJocystomata  and  adenocarcinomata,  and  even  on  histologic  examination  one 


CONDITION'S    OF   THE    TUBKS    AND    OVARIES. 


349 


is  frequently  unable  to  say  with  certainty  whether  or  not  the  given  specimen  is 
really  malignant. 

In  half  of  the  cases  the  carcinoma  was  bilateral.  From  the  tal)le  it  will  be 
seen  that  some  of  the  carcinomata  were  very  small  and  solid.  Others  had  be- 
come cystic,  and  in  at  least  two  cases  (Gyn.  Nos.  1637  and  9457)  the  malignant 
tumors  were  relatively  large. 

In  several  of  the  cases  the  disease  had  extended  to  other  structures.  In  Case 
8675  the  omentum  was  studded  with  secondary  growths. 

The  uterus,  in  most  of  the  cases,  contained  a  few  myomata  of  moderate  size. 
Only  in  Case  4020  did  the  myomata  reach  large  proportions. 

Where  carcinoma  of  the  ovary  and  myomata  exist,  the  better  plan  seems  to  be 
complete  removal  of  the  tubes,  ovaries,  and  uterus.  Seven  of  our  patients  w^ere 
operated  upon  and  all  recovered  temporarily. 


Fig.  243. — A  Dkrmoiu  Cyst  Associated  with  a  Myomatous  Uteri's.     (A  nat.  size.) 
Gyn.  No.  3960.     Path.  No.  971.     The  specimen  is  seen  from  behind.     The  increase  in  the  size  of  the  uterus  i< 
caused  by  subperitoneal  and  interstitial  myomata.     The  right  tube  and  ovary  are  normal.     The  specimen  has  been 
hardened,  and  the  left  ovary  cut  in  two.     The  solidified  sebaceous  material  fills  the  greater  part  of  the  cyst.    Pro- 
jecting from  the  lower  part  of  the  cyst  cavity  are  numerous  black  hairs. 

Dermoid  Cysts. — In  17*  of  the  934  cases  dermoid  cysts  wei-e  encountered. 
They  were  u.'^ually  unilateral,  and  fairly  evenly  distributed  between  the  right 
and  left  ovaries. 

The  smallest  dermoid  was  3  em.  in  diametei-,  the  largest,  17  em.  The  largest 
cyst  (Case  3232)  was  multilocular,  and  nearly  all  the  cysts  were  deiinoids.  It  is 
a  well-known  fact  that  dermoid  cysts  tend  to  become  adherent,  and  in  fully  two- 
thirds  of  our  cases  dense  adhesions  existed.  In  Fig.  243  we  have  an  example  of  a 
small  dermoid  cyst  associated  with  a  myomatous  uterus,  and  in  i''ig.  211  a  multi- 
nodular uterus  with  a  paro\'arian  cyst  on  the  I'ight  and  a  dei-nioid  cyst  of  the 
ovary  on  the  left. 

In  two  of  our  cases  ((Jyn.  Nos.  300S  and  l()()95).  the  patients  died.  In  the 
first  case  the  enucleation  of  the  jx'lvic  organs  was  exceedingly  ditlicuh,  and  the 
patient  died  with  signs  strongly  suggestive  of  infection  oi'  ol)sti'uetion.  Death 
in  the  second  case  was  suj)])ose(l  to  be  due  to  a  myocarditis. 

*Gyn.  Nos.  ;WOS,  .32:52.  3.')(K).  :5<)()(),  1S7;5,  01:52.  Till.  7.')()S.  771  I.  771i;.  SS7S.  lOOI),-).  ]()SS:5, 
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CONDITIONS    OF    THE    TUBES    AND    OVARIES. 


351 


Fibroma  of  the  Ovary. — In  3  out  of  934  cases  fibromata  of  the  ovar}-  were 
encountered  and  in  each  case  the  fibroma  was  unilateral.  In  Case  9090  the 
uterus  contained  several  small  myomata  and  the  left  ovary  had  been  transformed 
into  a  fibroma  12  x  14  x  16  cm. 

Attached  to  the  uterus  in  Case  3294  was  a  pedunculated  myoma  7  x  9  x  13  cm.; 
the  left  ovarv  had  been  converted  into  an  enormous  ftbroma,  16  x  24  x  30  cm. 


Fig.  245. — A  Very'  Largk  Lkkt  Ovarv  Assot-iATEu  with   a   Myomatous  Utkrus.     (Nut.  size.^ 
Gyn.  No.  57.34.     Path.  No.  2034.     The  tube  is  much  leiiRtlieiied,  and  near  its  center  is  covere*!  with  a  few 
bands  of  adhesions.     The  ovary  measures  2.5  .x  4  x  9  cm.      The  increase  in  .size  is  in  part  due  to  the  Oraatian  follicle, 
but   the  solid  portion  of  the  ovary  is  very  coarse  in  texture  and  much  increa.sed  in  amount.     (After  Howard  .\. 
Kelly.) 

The  multinodular  uterus  in  Case  10491  measured  10  \  17\2()('ni.;  dcNclopiutj; 
from  the  rif2;ht  ovary  was  a  fibroma  '>  .\  10  \  10  cm. 

The  occasional  association  of  (ibroina  of  the  o\'ary  with  ulcriiic  inyoinata  is 
of  interest  only  to  the  pathologist  and  has  no  cnnical  ini|)orl.  If  both  are 
present,  it  is  almost  impossible  to  make  a  (hagiiosis  before  o])('ration.  and  cN-en 
with  the  sy'XTimen  before  him  the  sur.ucon  at  times  mistakes  the  libroniM  for  a 
myoma  and  only  after  seeiii.ti  its  rclat  ions  to  1  he  I  nbc  or  on  incisino-  it  docs  he 
realize  the  exact  nature  of  the  <j^'o\\th. 


352 


MY(MATA    OK    THE    UTKRUS. 


Alterations  in  the  Location  of  the  Ovaries. — Willi  the  t'i('(|iu'nt  great  increase 
in  the  size  of  the  uterus,  due  to  the  continued  growth  of  the  niyoinata,  the  ovaries 
arc  gradually  tlrawn  away  fi'oni  tlu^r  usual  location,  l-'or  exani])le,  in  Case  4771 
the  left  ovary  and  the  sigmoid  fiexiu'e  were  drawn  high  uj)  on  the  surface  of  the 
tumor. 

With  the  migration  of  the  ovary  there  is  naturally  an  altered  relation  of  the 
ovarian  vessels,  and  they  may  be  found  high  up  on  the  side  of  the  tumor,  as  noted 
in  Case  4022. 

When  the  ovarian  vessels  su])ply  a  great  deal  of  the  nourishment  to  the  tumor, 
they  may  reach  large  proportions,  the  veins  in  some  cases  being  1.5  cm.  in  diam- 
eter, as  in  Case  9767. 


Fig. 

Gyn. 
The  tube 

The< 
it  is  not  I 
ovary  wa: 


246. — A  Greatly  Lexcithened-out  Ovary  .Associated  with  Uterine  Myomata.     (i  nat.  size.) 
No.  10102.     Path.  No.  6299.     The  tube  and  ovary  are  wedged  in  between  large  myomatous  ma-sses. 
has  been  converted  into  a  large  hydrosalpinx  and  is  adherent  to  one  of  the  myomata. 

)vary  was  markedly  increased  in  size,  being  3  x  13  cm.  Even  when  i)ictiired  about  half  its  natural  length 
inly  much  longer  than  normal,  but  also  much  thicker.  There  is  one  small  Graafian  follicle  cyst.  The 
s  slightly  edematous. 


In  some  cases  the  gi'eat  increase  in  size  of  the  veins  is  e\i(lently  due  to  com- 
pression of  the  uterine  veins  between  the  tumor  and  the  peh-ic  walls.  The 
ovarian  veins  then  return  more  venous  blood  than  is  theii-  wont.  The  alterations 
relative  to  the  pelvic  structures  must  be  most  carefully  borne  in  mind  by  the 
surgeon,  otherwise  the  rectum  or  ureters  may  suffer  serious  injury. 

Very  Large  Ovaries. — In  two  cases  what  might  be  termed  gigantic  ovaries  were 
found.  In  Case  57o4  the  utems  had  been  converted  into  a  nodular  tumor.  14  x 
19  X  27  cm.  The  right  ovary  was  rej)resented  by  a  cyst,  6  x  S  cm.  The  left  tube 
was  14  cm.  long,  and  the  ovary  w-as  much  enlarged,  being  2.5  x  4  x  9  cm.  (Fig. 
245).  Part  of  the  increase  in  size  was  due  to  a  cystic  Graafian  follicle,  but  the 
ovary  itself  was  much  enlarged.     In  Case  10102  the  abdomen,  to  within  S  cm.  of 


CONDITION'S    OF    THE    TUBES    AND    OVARIES. 


353 


the  costal  margin,  was  filled  with  a  hard  myomatous  tumor.  The  right  ovary 
was  greatly  enlarged,  measuring  3  x  10  cm.  (Fig.  246).  It  contained  a  cystic 
follicle,  but  the  great  increase  in  size  was  due  in  ])art  to  edema. 

The  Merging  of  a  Myoma  into  an  Ovary. — This  condition  is  exceptional.  In 
Path.  No.  4090  the  uterus  was  16  cm.  in  diameter  and  irregular  in  outline,  owing 
to  the  presence  of  numerous  myomata.  The  chief  interest  in  the  specimen  is 
centered  in  the  left  ovary,  which  was  apparently  7  cm.  in  length,  and  vari(Hl  from 
3  to  4  cm.  in  breadth.  The  outer  end  presents  the  characteristic  lobulated  ap- 
pearance, but  the  inner  end  is  exceedingly  dense  and  nodular  (Fig.  247).  On 
splitting  this  supposedly  large  ovary,  we  found  that  the  outer  third  Avas  com- 


FiG.   247. — The  Coalescence   of  a   Subperitoneal   Peuunculated  Myoma  with  an  Ovary,     (g  nat.  size.) 
Path.  No.  4090.     The  sketch  shows  a  small  portion  of  a  multinodular  uterus,   16  cm.  in  diameter.     The  left 
tube  is   normal.     Springing  from  the  surface  of  the  uterus,  just  behind  the  insertion  of  the  left  tube,  is  a  pedun- 
culated myoma,  the  outer  pole  of  which  has  grown  into  and  become  continuous  with  the  ovary. 

posed  of  ovarian  tissue,  which,  save  for  a  (Graafian  follicle  1.")  cm.  in  diameter, 
presented  the  usual  apjx'arance.  The  inner  two-thirds  consisted  of  a  sul)i)eri- 
toneal  myoma,  which,  on  account  of  its  jjroximity  to  the  ovary,  had  bui'i-owed 
into  it  in  the  manner  that  a  ball  would  fit  into  a  socket. 

Parovarian  Cysts. — Parovarian  cysts  were  noted  1!)  times  in  the  WM  cases  of 
uterine  myomata.  In  one  case  they  were  bilateral.  The.sc  cysts  varied  from 
1  cm.  to  20  cm.  in  diameter.  Fig.  244  is  an  excellent  illustration  of  a  parovarian 
cyst,  as  it  shows  cleai'ly  the  relation  of  the  cyst  to  the  tube  and  ovary,  and  also 
the  charticteristic  t  rniislucency.  The  opposite  ox'ary  is  the  seat  of  a  dermoid 
cyst. 


23 


CHAPTER  XIX. 

CONDITIONS    FOUND    IN    THE    LIGAMENTS   PASSING  TO   AND  FROM 
THE   UTERUS   IN  CASES   OF  UTERINE  MYOMATA. 

T.     Alterations  in  the  broad  ligaincnts. 
II.     Changes  in  the  utcro-ovarian  ligaments. 
III.     Changes  in  the  round  hgaments. 

I.  Alterations  in  the  Broad  Ligaments  Associated  ^x^ITH  Uterine  Myomata. 
As  a  rule,  the  broad  ligaments  show  no  alterations,  but  in  a  few  instances  we 
have  noted  marked  changes.     The  following  are  those  of  especial  interest: 

1 .  A  myoma  separating  the  folds  of  the  broad  ligament. 

2.  A  myoma  densely  adherent  to  the  posterior  surface  of  the  ])road  ligament. 
8.     Great  tlilatation  of  the  veins  of  the  broad  ligament. 

4.      Dilatecl  lymph-spaces  in  the  broad  ligament. 

o.     Cireat  thickening  of  the  broad  ligament,  usually  due  to  edema. 

G.     Al)scess  in  the  broad  ligament  secondary  to  a  tubo-ovarian  al)scess. 

Myomata  of  the  broad  ligament  and  adhesions  to  the  broad  ligament  are  dis- 
cussed in  the  chapter  on  Treatment  (p.  630). 

Dilatation  of  the  Vessels  of  the  Broad  Ligament. — As  a  rule,  after  s})litting  the 
jH'ritoneum  of  the  broad  ligament  the  oj)ei-ator  can  readily  free  a  .myoma  in 
this  region,  but  in  some  cases  great  congeries  of  blood-vessels — chiefly  veins 
— occupy  the  bi'oad  ligament  and,  if  not  gently  handled,  ruptiuv  and  a 
troublesome,  if  not  alarming,  hemorrhage  may  ensue. 

In  Gyn.  Xo.  77  the  abdomen  was  filled  with  a  nmltinodular  myomatous 
uterus.     The  \-eins  in  both  broad  ligaments  were  enormously  distended. 

In  Gyn.  .\o.  0129  the  myomatous  uterus  extended  almost  to  the  umbilicus. 
The  surface  of  the  tumor  was  covered  with  numerous  vessels,  and  vovy  large 
veins  course»d  over  the  bi'oad  ligament.  Many  ligatures  were  required  to  com- 
pletely cont  rol  the  bleeding  from  these  vessels. 

In  Gyn.  No.  7237  the  fundus  was  the  size  of  a  cocoanut  and  smooth.  Cours- 
ing over  its  surface  were  large  tortuous  vessels.  The  broad  ligaments  with  the 
greatly  engorged  tortuous  vessels  were  di'awn  well  upon  each  side  of  the  tumor. 
When  the  broad  ligaments  were  split,  these  veins  looked  like  large  earth-worms. 

The  large  myoma  in  Case  S526  had  d(>veloped  chieHy  in  the  right  broad 
ligament,  and  the  vessels  on  this  side  were  much  dilated. 

The  increase  in  size  of  the  vessels  of  the  broad  ligament  in  these  cases  did  not 
appear  to  be  due  in  any  measui-e  to  obstruction,  but  rathei'  to  the  great  vascu- 
larity of  the  tumor. 

354 


CONDITIONS    FOUND    IN    THE    LIGAMENTS.  355 

Parovarium. — In  some  cases  the  vessels  passing  between  the  tube  and 
ovary  are  greatly  enlarged.  This  is  prone  to  occur  when  the  tumor  is  of  large 
proportions  and  requires  nuich  nourishment,  or  when  the  return  of  the  venous 
flow  from  the  uterus  is  retarded  as  a  result  of  ])ressure. 

Occasionally  the  parovarian  tissue  is  nuich  thickened  and  translucent.  This 
may  be  due  to  edema,  as  in  Case  3296,  or  to  marked  dilatation  of  the  lymphatics, 
as  in  C.  H.  I.,  Case  B.,  operated  upon  March  13,  1905. 

Dilated  Lymph-spaces  in  the  Broad  Ligament. — On  p.  14  we  discussed  dilated 
lymphatics  in  the  omentum  associated  with  parasitic  myomata,  and  on  p.  72 
dilated  uterine  lymphatics.  If  such  conditions  occur  in  the  uterus,  it  is  but 
natural  that  we  should  find  them  in  the  broad  ligaments.  A  reference  to  Fig. 
57,  p.  73,  will  show  greatly  dilated  lymph-vessels  coursing  over  the  surface  of 
the  uterus,  and  becoming  lost  between  the  tube  and  ovary. 

In  Case  5141,*  in  which  the  myomatous  uterus  extended  far  above  the  um- 
bilicus, it  was  found  that  the  myoma  had  developed  to  a  large  extent  in  the  left 
broad  ligament.     In  both  broad  ligaments  were  many  dilated  lymph-spaces. 

The  dilated  lymphatics  at  operation  stand  out  sharply,  but  after  operation 
collai)se  and  are  readily  overlooked. 

Thickening  of  the  Broad  Ligament  in  Cases  of  Uterine  Myomata. — Occasion- 
ally the  Inroad  ligaments  are  not  only  thickened,  but  also  drawn  upward  to  a 
considerable  extent  by  the  myoma.     The  thickening  is  usually  due  to  edema. 

In  Case  6190  the  uterus  was  enlarged  and  adherent,  and  on  both  sides  were 
cystic  appendages.     The  right  broad  ligament  was  thickened  and  edematous. 

In  Case  7528  the  myomatous  uterus  extended  9  cm.  above  the  umbilicus. 
There  were  broad  adhesions  between  the  ileum  and  broad  ligament.  There  was 
extensive  edema  in  both  broad  ligaments. 

In  Case  6863  the  uterus  contained  several  myomata  and  there  were  adhesions. 
Both  broad  ligaments  were  very  edematous  and  thickened,  and  were  di-aA\'n  up 
over  the  fundus. 

The  myomatous  uterus  in  Case  7064  was  ])artially  eiiNcloped  in  adhesions. 
The  left  broad  ligament  was  swollen  and  edematous;  it  contained  mai'kedly 
dilated  veins,  and  was  drawn  up  ()\-er  and  adherent  to  the  fundus. 

It  will  be  noted  that  in  each  of  these  four  cases  in  which  edema  of  one  or 
both  broad  ligaments  existed,  ]'eni;iins  of  peKic  in(l;iniiiiatioii  wci'e  present. 

Abscess  in  the  Broad  Ligament. This  condil  ion,  so  connnon  after  a  post  j)uer- 
peial  infection,  is  i-;ii'ely  associated  with  inyoni;i.  In  Case  7313  the  nmltino(hilar 
myomatous  uterus  contained  sarcoiuatous  nodules.  The  I'ight  tul)o-o\"ai'ian 
abscess  h;id  opened  into  l  he  blond  huMnielil.  It  li;iil  iheli  i)UI'rowe(l  hack  to  the 
rectum,  and  extended  to  the  tissue  (hreclly  beneath  the  xaginal  mucosa.  This 
case  is  reported  in  detail  in  the  chaptei'  ou  Sarcoui.a  (p.  I!).")). 

M>oiiiata  thenise|\-es  rarely,  if  e\-er,  gi\-e  rise  to  an  .abscess  in  the  broad 
ligament. 

*  Tiii.s  case  \v;is  rc|>()rt('(l  in  detail  l)y  Tliomas  S.  Ciillrn,  in  llic  .loliii^  Il()i)kins  Hiillctiii,  Octo- 
l)cr,  1S97. 


356 


MVOMATA    OF    THK    UTKRUS. 


II.  Changes  in  the  Utero-ovarian  Ligaments. 
In  sonic  eases  the  altei-ations  are  minor  in  character.  For  example,  as  a 
resuh  of  pressure  from  the  ciihn;tietl  uterus,  the  utero-ovarian  ligaments  may  be 
much  flattened,  as  in  San.  ^io.  1924.  In  other  eases  in  which  the  uterus  is  much 
enlarged  and  there  is  hypertro])hy  of  the  uterine  muscle  the  ligaments  may  be 
abnormally  de^•el()j)e(l.  This  was  particularly  noticeable  in  Case  8866.  The 
uterus  measured  26x25x12  cm.,  the  chief  development  being  in  the  cervical 
jiortion;  the  utero-ovarian  ligaments  were  unusually  well  developed. 

In  our  experience  tumors  of  the  utero-ovai'ian  ligaments  have  been  of  four 
varieties : 

(1)    Cysts.     (2)    Myomata.     (3)    Adenomyomata.     (4)    Sarcoma    (primary 

growth  in  the  uterus). 

Cysts  of  the  Utero-ovarian  Liga- 
ments.— We  have  had  two  in- 
stances. In  Case  2763  a  the  myo- 
matous uterus  measured  6xl4x 
20  em.  in  its  various  diameters. 
Ill  the  right  utero-ovarian  liga- 
ment was  an  oval  cyst,  4.5  by  3 
cm.  (Fig.  24S).  Unfortunately, 
the  specimen  was  lost,  and  no 
j  histologic  examination  could  be 
made. 

In  Case  6667  the  myomatous 
uterus  was  18x15x12  cm.  The 
right  tube  was  normal.  The  ovary 
was  drawn  out,  l)(>ing  2x5x7  cm. 
The  increase  in  size  was  caused 
by  several  large  follicles.  Situated 
in  the  utero-ovarian  ligament 
were  several  small  cysts  containing  a  clear  fluid  (Fig.  249).  Microscopically, 
these  cysts  were  evidently  dilated  (Ii'aafian  follicles.  This  is  the  only  instance 
in  which  we  have  ever  found  the  ovarian  elements  in  the  utero-ovarian  ligament. 
\\'hen  one  examines  the  drawing  carefully,  it  is  seen  that  the  ovary  is  dis{)laced 
unusually  far  out,  thus  making  the  ligament  abnormally  long.  Had  the  ovary 
been  in  its  normal  ])Osition,  these  apparently  aberrant  ovarian  structures  would 
in  all  ])robability  have  been  included  in  the  ovary. 


Fig.  248. — Cyst  of  the  Utero-ovarian   Ligament. 

(i  nat.  size.) 
Gyn.  No.  2763  a.  Path.  No.  286.  .\ttached  to  a  large 
myomatous  uterus  is  an  occluded  right  tube,  on  the  surface 
of  which  are  a  few  small  subperitoneal  cysts.  The  ovary  is 
considerably  drawn  out.  Incorporated  in  the  right  utero- 
ovarian  ligament  is  an  oval,  thin-walled  cyst  with  two  small 
secondary  cysts  on  its  inner  side.  The  cyst  measured  4.5  by 
.3  cm. 


Gyn.  No.  2763  a.     Path.  No.  286. 

M  y  o  111  a  t  o  u  s   u  t  e  r  u  s   w  i  t  ii   a  d  h  c  r  e  11  t    a  j)  p  c  11  d  a  g  e  s  a  n  d   a 
cyst   in   the   right   utero-ovarian    ligament    ( Fig.  248). 

J.  R.,  white,  aged  forty-four,  married.     Admitted  May  4;    discharged  June 


CONDITIONS    FOUND    IN    THE    LIGAMKXTS. 


357 


19,  1894.     The  myomatous  uterus  was  large,  irregulai',  and  filled  the  pelvis  and 
lower  part  of  the  al)donien. 

Operation,  May  7,  1894.  Hysteromyomectomy.  The  chief  interest  in  the 
case  is  centered  in  the  appendages  on  the  right  side  (Fig.  248).  The  tube  is  the 
seat  of  a  hydrosalpinx  and  the  ovary  is  drawn  out.  Situated  in  the  right  utero- 
ovarian  ligament  is  a  cyst  4.5  x  3  cm.     No  histologic  examination  was  made. 


G3ni.  No.  6667.     Path.  No.  2900. 

e  m  y  o  m  a  t  a  ; 
0  n  e  a  1 ,  inter- 
a  n  d  s  u  b  m  u  c  - 
a  fi  a  n  follicle 
he  right  side; 
y  s  t  s  in  the 
a  r  i  a  n  1  i  g  a  - 

249). 


Fii;.  249. — CvsTS  in  tuk  Utkro-ovaiuan  Li(iAMi;NT.     (1  nat.  size.) 
Gyn.  No.  6667.     I'ath.  No.  2900.     Attached  to  the  large  imiltinodular  inyoinatous  uterus  are  the  right  tube 
and  ovary.     The  ovary  contains  two  dilated  follicles.     In  the  right  iitero-ovarian  ligament  are  three  cysts.     On 
histologic  examination  they  are  found  to  be  typical  (iraafiaii  fnllicli--. 

A.  \'..  colored,  ngcd  tlii  i-ty-ciglit ,  mairiccl.  Adtiiillcd  .laniiary  27:  dis- 
charged February  27,  bSi)!). 

( )peral  ion,  hystcromyoiiiect  oiiiy. 

I'alli.  Xo.  2!)()().  The  specimen  coiisisis  of  the  utefus,  tul)es.  and  o\ai'ies. 
'Hie  uteiiis  is  a  no(hila!'  luiiioi',  JN  \  1")  \  12  cm.  S])ringing  from  its  surface, 
chieliy  from  the  fuiuhis,  are  numerous  ))e(hiiicuhit<'(l  and  sessile  myomata,  \'arv- 
ing  from  1  to  0  cm.  in  diameter,  'i'he  ulei'ine  ca\ity  is  oc(aipied  b\-  a  large 
submucous  myoma  and  two  smaller  ones.  This  large  myoma  is  j)ear-sha))ed 
and  11  cm.  in   diameter.     Our  chief  interest   centers  in  the   iii:iit  utero-oN'arian 


358  MVO.MATA    OF    THK    LTKRIS. 

ligaiuciit.  The  tube  is  iiornial,  the  ovary  is  much  di-awii  out,  and  situated  in 
the  utcro-ovariaii  liiiaincnt  is  an  oval  cyst,  2  x  1  cm.  (Fig.  249.)  Near  the 
uterus  is  a  small  cyst,  7  x  ')  mm.  There  are  no  adhesions.  The  left  tube  is 
normal.     The  left  ovary  contains  a  thin-walled  cyst. 

Microscopic  sections  from  the  small  cysts  in  the  rigiit  utero-ovai'ian  ligament 
show  that  they  are  typical  (!i-aatian  follicles,  and  that  they  are  essentially  ovarian 
elem('nt>. 

Myomata  of  the  Utero-ovarian  Ligaments. — W  v  have  had  five  cases  of  this 
character,  ami  all  were  associated  with  uterine  myomata.  They  varied  from  1 
to  4.5  cm.  in  diameter.  Tn  Case  4609  there  was  a  nuiltinodular  uterus,  12  cm. 
in  diameter.  Situated  in  the  upper  border  of  the  right  ovarian  ligament  was  a 
myoma,  1  x  0.7  x  0.7  cm.  In  Case  4869  an  irregularly  globular  myomatous  uterus 
averaged  16  cm.  in  diameter.  Springing  from  the  left  utero-ovarian  ligament, 
about  its  middle,  was  a  myoma  about  2  x  2.3  cm.  (Fig.  250). 

In  Case  7859  the  uterus  had  been  converted  into  a  nodular  tumor,  a))proxi- 
mately  12  x  10  x  10  cm.  Histologic  examination  showed  that  the  uterus  was  the 
seat  of  a  diffuse  myoma.  Situated  in  the  right  utero-ovarian  ligament  was  a 
myoma  2.5  cm.  in  diameter. 

In  Case  4252  the  myomatous  uterus  was  adherent  to  the  pelvic  floor  and  to 
the  rectum.  In  the  right  utero-ovarian  ligament  was  a  myoma  2.5  x  2.5  cm. 
(Fig.  251). 

In  Case  9()/5  the  myomatous  uterus  was  free  from  adhesions.  Sj)ringing 
from  the  anterior  aspect  of  the  right  utero-ovarian  ligament  was  a  globular 
myomatous  nodule.  4.5  cm.  in  diameter  (Fig.  252).  The  right  tube  and  ovary 
were  normal. 

On  histologic  examination  these  myomata  all  j)roved  to  l)e  identical  in  struc- 
ture, as  they  naturally  would  be,  with  those  developing  in  the  uterus. 

Gyn.  No.  4609.     Path.  Nos.  1307  and  1318. 

S  u  b  p  e  r  i  t  o  n  e  a  1  a  n  d  interstitial  u  t  e  r  i  n  e  m  y  o  m  a  t  a , 
s  u  ))  p  u  rati  n  g  s  u  b  m  u  c  o  u  s  m  y  o  m  a  ;  small  m  y  o  m  a  o  f  t  h  e 
right    o  V  a  r  i  a  11    1  i  g  a  m  cut  ;    g  o  n  o  r  r  h  e  a  1    salpingitis. 

M.  T.,  white,  married,  aged  fifty-two.  .\dinitt(>d  August  31;  died  Sep- 
tembei-  19.  1S9().  When  the  ])atient  was  ojK'rated  upon  she  was  in  a  very  weak- 
ened condition;  the  urine  contained  albumin  and  casts. 

Operation,  September  14,  1896.     Hysteromyomectomy. 

Path.  No.  1318.  The  uterus  is  irregularly  globular,  measuring  approxi- 
mately 12  cm.  in  diameter.  Springing  from  its  surface  are  several  hrm,  flattened 
bosses  and  two  subperitoneal  nodules,  3  cm.  in  diameter.  The  uterine  walls 
contain  numeidus  myomatous  nodules,  varying  from  0.5  to  S  cm.  in  dianu^ter. 
Tile  largest  of  these  is  situated  ill  the  posterior  wall :  the  central  portion  has  been 
converted  into  two  large  cavities  lined  with  a  greenish  yellow,  exceedingly  friable 
material.     There  are  several  submucous  myomata,   one  greenish  yellow  and 


COXDITIOXS    P^OUXD    l.\    THE    LIGAMENTS. 


359 


suppurating.  On  the  left  side  the  appendages  are  normal.  On  the  right  side  the 
ovary  is  covered  with  a  few  delicate  adhesions.  Situated  in  the  upper  border  of 
the  right  utero-ovarian  ligament  is  a  firm  myomatous  nodule,  1  x  0.7  x  0.7 
cm.  This  presents  a  glistening  white  surface  and  is  composed  of  fibers  con- 
centrically arranged. 

Gyn.  No.  4869.     Path.  No.  1434. 

Interstitial  uterine  m  y  o  m  a  t  a  ;  slight  j)  e  1  v  i  c  a  d  - 
h  e  s  i  0  n  s  ;  small  m  y  o  m  a  in  the  left  u  t  e  r  o  -  o  v  a  i-  i  a  n 
ligament   (Fig.  250) . 

E.  G.,  colored,  married,  aged  thirty-four.  Admitted  December  9,  1896; 
discharged  January  17,  1897. 

Operation.     HysteromA'omectomy. 

Path.  No.  1434.  The  uterus  is  irregularly  globular,  averaging  16  cm.  in 
diameter.  Occupying  the 
posterior  wall,  and  extend- 
ing do^^'n  below  the  cervix, 
is  a  tumor  17  x  16  cm., 
presenting  the  usual  myo- 
matous appearance.  On 
the  right  side  the  append- 
ages are  covered  with  a 
few  adhesions.  On  the 
left  side  the  tube  is  sev- 
eral centimeters  long,  and 
the  fimbriae  are  slightly 
adherent  to  one  another. 
The  ovary  is  covered  with 
a  few  vascular  adhesions. 

Springing  fi'oin  the  left  utero-ovarian  ligament  altout  lis  middle  is  a  tii}-o!iia.  2 
X  2.:]  cm.  (Fig.  250 ). 

Gyn.  No.  7859.     Path.  No.  4122. 

M  u  I  t  i  )i  o  d  11  I  a  V  III  y  o  m  a  t  o  u  s  u  I  v  v  u  s  :  d  i  tT  u  s  v  a  d  e  n  o  - 
m  y  o  m  a  of  t  li  f  bo  d  y  :  n  u  m  e  r  o  u  s  a  d  h  e  s  i  o  n  s  ;  rig  h  t 
li  y  d  r  o  s  a  1  |)  i  n  \  . 

S|)riiiging  from  the  right  utero-ovarian  ligament  is  a  small  myoma,  2.5  cm.  in 
diameter.     Tiiis  case  is  reported  in  detail  in  "  .\denomyoma  of  the  Uterus,'"  p.  109. 

Gyn.  No.  4252. 

-M  y  o  III  a  t  o  11  s  u  I  ('  r  u  s  w  i  1  h  a  111  \-  o  m  a  i  11  I  li  c  r  i  g  h  t 
u  t  ('  r  o-  o  V  a  r  i  a  11     1  i  g  a  111  cut     ( i'ig.  25!  ). 

.\.  ('..  aged  forty,  iiiarricd.     .Vdmittcd   Maicli   2S:   dischai-gcd  May  9.    1S<)(). 
Operation.      ilystcroiiiy(»nicctoiiiy.     Tlic  niyoiiiatoiis  uterus  was  ret rollexed 


Fig.  250. — Myoma  of  the  Utkro-o%  arian  LKiAMKxr.      (V  nat.  size.) 
Gyn.  No.  4869.     Path.  No.  1434.     Situated  ou  the  posterior  surface 
of   the   left   utero-ovarian    ligament  near    its  middle  is  a  myoma  (a). 
This  measures  2  x  2.3  cm. 


360 


MVOMATA    OF   THE    UTERUS. 


and  adherent  to  the  jx'lvie  iUmv.     Situated  in  the  right  utero-ovarian  Hganient 
was  a  niyoina,  'A.n  by  2.5  em.  (P'ig.  251). 


r  i  ";  h  t       ii  t  e  r  o 


Gyn.  No.  9675.     Path.  No.  5870. 
U  t  e  r  i  n  e      ni  y  o  ni  a  t  a  ;      m  y  o  ni  a      of       t  h  e 
ovarian    1  i  g  a  ni  0  n  t    (Fig.  252). 

N.  B.,  aged  forty-three,  -white,  single.  Admitted  Ahiy  27;  died  June  3, 
1902. 

On  admission  she  was  suffering  from  chronic  nephritis. 

Operation.  Hysteromyomectoniy.  The  uterus  extended  as  high  as  the  um- 
l)iHeu8.  Situated  in  the  right  utc^'o-ovarian  ligament  was  a  myoma,  4.5  cm.  in 
diameter.     In  this  ease  the  fatal  result  was  due  to  the  nc-jjhritis. 

Adenomyoma  of  the  Utero-ovarian  Ligament, — This  condition  is  an  exceed- 
ingly rare  one,  and  we  have  had  only  one 
example  (San.  No.  1872).  The  uterus  was 
14  cm.  in  length  and  13  cm.  broad.  Pro- 
jecting from  its  surface  were  myomata 
varying  from  2  to  9  cm.  in  diameter.  His- 
tologic examination  showed  that  the 
mucosa  manifested  a  definite  tendency  to 
extend  into  the  nmscle. 

Lying   perfectly  free  from  the  uterus, 
and   attached   to    the    utero-ovarian    liga- 
ment, was  a  pear-shaped  myoma,  6  cm.  in 
length,    and    varying   from   3  to  4  cm.   in 
thickness.     Projecting    slightly    from    its 
surface  were  cysts,  one  of  which  reached  1 
cm.  in   diameter.     On   section,   numerous 
cystic      spaces      were      found      scattered 
throughout    the   myoma.     Some  of  these 
were  filled  with  old  coagulated  l)lood  and  had  a  brown  lining.     Scattered  here 
and  there  throughout  the  ti.ssue  were  light-brown,  porous  areas,  suggesting  mu- 
cosa.    Even  macroscopically  the  diagnosis  of  adenomyoma  was  easy. 

On  histologic  examination  some  of  the  cysts  were  found  to  be  dilated  glands; 
others  were  distended  miniature  uterine  cavities.  The  jjorous  areas  were  masses 
of  typical  uterine  mucosa. 

The  case  is  described  in  detail  in  "Adenomyoma  of  the  Uterus,''  p.  140  (Figs. 
41  and  42). 

Secondary  Sarcomatous  Nodule  in  the  Utero-ovarian  Ligament. — In  Case  8610 
(described  in  detail  in  the  chapter  on  Sarcoma,  j).  231)  the  uterus  was  approxi- 
mately 12  x  14  cm.,  and  was  studded  with  sarcomatous  nodules.  Histologic  ex- 
amination strongly  indicated  that  the  sarcoma  had  resulted  from  a  malignant 
change  in  the  myomata.     Situated  in  the  right  utero-ovarian  ligament  was  a 


Fig.  251. — Myoma  of  thk  Right  Utkro-ova- 
KiAN"  Ligamf;nt. 
Gyn.  No.  4252.  To  the  left  is  a  small  por- 
tion of  the  myomatous  uterus.  Occupying  the 
central  portion  of  the  right  utero-ovarian  liga- 
ment is  a  myoma  which  measured  2.5  x  3.5  cm. 


CONDITIONS    FOUND    IN    THE    LIGAMENTS. 


361 


sarcomatous  nodule,  1.5  cm.  in  diameter.  This  on  section  was  perfectly  white 
in  color,  homogeneous  in  consistence,  and  resembled  the  sarcomatous  uterine 
nodules. 

III.  Changes  in  the  Round  Ligaments  in  Cases  of  Uterine  Myomata. 
With  the  increased  size  of  the  uterus  it  is  but  natural  that  alterations  in  one 
or  both  round  ligaments  should  be  met  with.     We  have  found  the  following  in- 
teresting conditions  in  our  scries: 

1.  An  altered  relation  of  one  round  ligament  to  the  opposite  one. 

2.  The  round  ligament  as  a  tense  band. 

3.  Great  lengthening  of  the  round  ligament. 

4.  Hypertrophy   of   the   round   ligament. 


I'm.  252. — MyoM\  of  the  Utkko-ovakian  I,i<;ami:nt.     (V  nat.  size.) 

Gyn.  No.  967,5.     Path.  No.  5870.     The  right  tube  and  ovary  are  normal.     GrowiniB;  from  the   anterior  aspect 

of  the  right  utero-ovarian  hgameiit,  and  free  from  the  uterus,  is  a  globular  myoma,  4.5  cm.  in  diameter. 


5.  Myoma  of  the  round  ligamciil. 

6.  Adenomyoma  of  the  round  ligaiin'iil . 

Altered  Relations  of  One  Round  Ligament  to  its  Fellow.  The  iclarKtii  of  the 
ends  of  the  I'ouiid  ligaments  to  one  aiiothci-  is  often  an  imporlanl  jtoinl  in  the 
diagnosis  between  j)regnancy  and  inyoina.  In  some  cases,  on  opening  the  ab- 
domen, the  surgeon,  from  t  he  geiieial  eonioui'  of  t  he  ntems,  cannot  exclude  preg- 
nancy, although  the  clinical  hisloiy  in  no  \\.a\'  suggests  it.  ()ften  a  glance  at  the 
uterine  insei'tion  ot   llie  rouml  liuaiiients  will  show  that   the\'  are  not  over  a  few 


362 


MVUMATA    OF    TMK    LTHIUS. 


C'ciitinictcrs  ;i));u-t.  altliou^'li  the  iitcnis  is  as  largo  as  that  of  a  six  months'  prog- 
nancy.  This  will  usually  indicate  that  the  onlargemcnt  is  duo  to  a  tumor  sit- 
uatod  in  tho  posterior  wall.  In  other  cases  when  a  myoma  is  developing  in  one 
side  of  th{^  uterus  the  corros])onding  round  ligament  is  drawn  far  up  and  is  ap- 
])arenlly  inserted  at  a  higher  level  than  its  fellow  opposite.  When  pregnancy 
exists,  there  is  usually  an  equable  enlargement  of  the  uterus,  and  although  the 
distance  between  the  round  ligaments  increases,  their  points  of  uterine  attach- 
ment remain  on  the  same  level. 

In  Case  8371,  when  the  abdomen  was  opened,  we  at  first  suspected  pregnancy, 
but  a  glance  at  the  round  ligament  at  once  solved  tho  problem. 

The  Round  Ligament  as  a  Tense  Band. — As  a  rul(\  bimanual  examination 
will  enable  one  to  get  only  a  general  idea  of  the  contour  of  the  myomatous  uterus 
and  to  determine  whether  the  tumor  is  fi'eely  movable  or  fixed.  Occasionally, 
as  in  Case  13025,  the  ligament  may  be  outlined  as  a  tense  cord.  In  this  case  the 
tumor  had  developcnl  from  the  fundus  on  the  right  side,  and  had  drawn  the  right 
cornu  high  up  into  the  abdomen.     The  right  round  ligament  was  6  inches  in 


V   3<2<^^<S^. 


Fig.  2.53. — Mvoma  of  the  Rorxn  Ligamk.xt.      (Nat.  size.) 
B.  H.,  December  5,  1908.     The  uterus  is  normal  in  size,  but  the  left  tube  is  .slightly  thicker  than  usual.    SpriiiK- 
ing  from  the  upper  border  of  the  left  round  ligament,  about  2  cm.  from  the  uterus,  is  a  myoma  over  1  cm.  in  di- 
ameter,    n  was  freely  movablf. 

length,  and  on  bimanual  examination,  with  the  ])atient  under  ether,  it  was  felt  as 
a  tense  band  running  from  the  right  inguinal  ring  to  a  point  near  the  summit 
of  the  tumor. 

Great  Lengthening  of  the  Round  Ligaments. — As  one  end  of  the  round  liga- 
ment emerges  fi-om  the  inguinal  canal  and  the  other  merges  into  the  lateral  and 
anterior  aspect  of  the  uterus,  it  is  but  natural  that  any  uterine  tumor  that  en- 
larges or  draws  up  the  uterus  .should  at  the  same  time  cause  a  lengthening  of  the 
round  ligament.  In  our  experience  increased  lengthening  of  the  round  ligaments 
has  not  caused  a  corresjxmding  diminution  in  their  diameters. 

Tn  Ca.se  6915  the  left  round  ligament  was  enormously  lengthened  out  and 
almost  lo.st  in  the  tumor. 

In  C.  H.  I.  (McA.)  an  S!)-])()und  sub[)ei-itoneal  myoma  filled  the  alxlomeii. 


CONDITIONS    FOUND    IX    TH  H    IJCAMENTS. 


363 


The  uterus  lay  near  the  hver,  and  the  round  ligaments  were  greatly  length- 
ened. 

Hypertrophy  of  the  Round  Ligaments. — As  a  rule,  the  round  ligaments  are  of 
the  usual  diameters,  even  when  myomata  exist.  Occasionally,  however,  they  are 
greatly  hypertrophied. 

In  Case  8024  the  uterus  was  about  the  size  of  that  of  a  six  months'  pregnancy. 
Both  round  ligaments  were  greatly  hypertro))hied. 

Both  round  ligaments  were  greatly  lengthened  and  thickened  in  Case  5103, 
in  which  the  lower  half  of  the  abdomen  was  filled  with  a  multinodular  myo- 
matous uterus. 

From  an  operative  standpoint,  it  is  always  wise  to  be  particularly  careful  that 
the  round  ligament  is  properly 
ligated.  On  several  occasions 
we  have  seen  the  round  liga- 
ment slip  away  from  its  ligature 
during  the  course  of  the  opera- 
tion, and  considerable  oozing 
follow.  When  there  is  much 
hypertrophy,  the  vessels  are 
often  of  goodly  size,  and  if  not 
carefully  tied,  may  later  give 
rise  to  alarming  bleeding. 

Myoma  of  the  Round  Liga- 
ment.— Four  of  our  myomatous 
uteri  have  been  associated  with 
myoma  of  the  round  ligament. 
In  Case  8713  the  multinodular 
myomatous  uterus  was  the  size 
of  a  child's  head,  and  situated 
in  the  right  round  ligament  was 
a  myomatous  nodule. 

In  Case  10()()9,  Path.  No. 
6908,  the  nodular  uterus  was 
10  X  6  X  6  cm.  Situated  in 
the  right  round  ligament  was  a  iiiyoma  7  cm.  in  diameter. 

Quite  recently  another  myoma  of  the  I'ouiid  ligament  was  found:  this  is 
shown  in  Fig.  253. 

The  myomatous  uterus  ill  San.  .\o.  l()5S(Pa!li.  .Xo.  KiKl)  was  20  \  20  \  12  em. 
Situated  in  the  right  round  ligaiiieiit  was  a  inyoiiia.  6  x  3  \  3  em.,  separated  from 
the  uterus  by  at  least  1  em.  of  iioniial  round  ngaineiit. 

The  nmscle  of  the  round  hganieiil  is  identical  in  characler  with  that  compo.s- 
ing  the  uterus,  and  myomata  of  the  round  hgaiiieiit  accordingly  present  the  same 
gross  and  histologic  jiictures. 


254. — .\    MvoMA    LviMi    Fhkk     kko.m    the    I'tkrus    .\xi) 

.SlTU.\TED  BeTWKK.N  THE  TuBE  AND  OvARV.    (Nat.  size.) 

Path.  No.  8432.  The  tube  is  thickened,  owing  to  a  sac- 
cvilated  salpingitis,  n  is  rare  to  have  the  fimbriated  end  open 
when  such  a  condition  exists.  The  ovary  has  been  converted 
into  a  corpus  luteuni  cyst,  a  is  a  small  corpus  hiteum.  Sit- 
uated between  the  tube  and  ovary,  and  lying  near  the  inner 
end  of  the  tube,  is  a  small  inMhilar  nudiua. 


364  MYOMATA  OF  THK  ITKRUS. 

Adenomyomata  of  the  Round  Ligament. — This  condition  is  exceedingly  rare. 
It  fell  to  our  lot  to  record  the  first  case  of  this  character.* 

\'aginal  examination  did  not  indicate  any  increase  in  size  of  the  uterus.  Oc- 
cu{)yin<i;  the  uj)per  ])art  of  the  I'iiiht  labium  was  an  irregular  mass,  about  2  cm.  in 
diameter.  On  removal  it  ])ro\cd  to  be  an  adenomyoma  of  the  round  ligament. 
About  eighteen  months  later  another  myoma  was  removed  from  the  left  round 
ligament  in  the  inguinal  region.  This  case  is  reported  in  detail  in  '' Adenomyoma 
of  the  Uterus,"  p.  2o(). 

Small  Myoma  Unattached  to  the  Uterus  and  Situated  between  the  Tube  and 
Ovary. — In  Path.  No.  8432  we  have  a  tul)e  that  is  the  seat  of  a  mild  inflannnation, 
l)ut  nevertheless  has  a  patent  fimbriated  end.  The  ovary  contains  a  corpus 
luteum  cyst.  At  the  inner  end  of  the  tube,  and  lying  between  it  and  the  enlarged 
ovary,  is  a  small  myoma  (Fig.  254).     It  is  entirely  free  from  the  uterus. 

*  Thomas  S.  ('ullen,  Adenomyoma  of  the  Round  Ligament,  Johns  Hopkins  Hospital  Bulletin, 
May  and  June,  1S96.  Further  Remarks  on  Adenomyoma  of  tiie  Round  Ligament,  Johns  Hop- 
kins Hospital  Bulletin.  .Tune,  1898. 


CPIAPTKR  XX. 

THE   BLADDER   IN  CASES  OF  UTERINE   MYOMATA. 

Position  of  the  Bladder. 

In  the  majority  of  our  cases  the  blacUler  had  retained  its  normal  position; 
nevertheless,  not  infrequently*  it  had  been  carried  up  into  the  abdomen.  This 
displacement  of  the  bladder  is  dependent  upon  two  main  factors:  (1)  Upward 
pressure  by  subvesical  myomata.  (2)  The  gradual  ascent  of  the  bladder  ^^^th 
the  continued  growth  of  the  myomatous  uterus. 

The  Upward  Pressure  of  Subvesical  and  Intraligamentary  Myomata. — ^^'hen 
a  myomatous  nodule  develops  in  the  lower  segment  of  the  uterus  and  spreads 


Fir:.  255. — A  Subvesical  Myoma. 

Gyn.  No.  4.340.  Projecting  from  the  ante- 
rior surface  of  the  uterus  and  encroaching  on  the 
bladder  is  a  subvesical  myoma  which  meiusureil 
4x4.5x8.5  cm.     A  myomectomy  was  done. 

Although  the  nodule  greatly  tliminished  the 
mobility  of  the  bladder,  there  were  no  local 
symptoms. 


Fig.  256. — A  Bladder  Forced  out  ok  the  Pelvis  by 
AX  Incarcerated  Myomatous  Uterus. 

Gyn.  No.  7630.  Occupying  the  posterior  wall  of  the 
uterus  is  a  large  myomatous  nodule.  The  uterus  is  firmly 
fixed  in  the  pelvis  by  rectal  adhesions,  as  indicated  by  a. 

The  bladder,  even  when  emptied,  extends  to  within 
4  cm.  of  the  umbilicus.      Its  walls  are  much  thickened. 


out  beneath  the  l)ladder,  the  latter  is  naturally  caiTicd  upward  on  its  suii'ai'c  .\ 
similar  condition  may  also  be  pnxhiccd  by  a  large  inyoinatous  uterus  becoming 
impacted  in  the  pelvis;  much  j)ressure  is  then  exercised  in  all  directions  and  the 
bladder  is  forced  into  the  abdomen. 

*  Displacement  upward  of  the  bladder  wa.s  noted  in  Ca.ses  HiSL',  1703.  17.')2,  2777,  2X22.  8113, 
3133,  3218,  3340,  3445,  3H42,  3882,  4020,  4022.  4285,  4293.  4340,  4771.  4801  J.  4832,  4002,  5086, 
5332,  6178,  6206,  6376,  ()582,  6628,  6863,  6015,  7049,  70()4,  722(),  7237,  7240,  7597,  7()30,  7832, 
8008,8368,8866,10778,  10969,  lllSO,  11792,  12194,  12520,  12841 .  12864,  and  13016.  Displace- 
ment was  un(ioul)te(lly  present  in  oilier  eases  in  wiiidi  no  note  was  in;idc  at  openilion. 

365 


366 


MVO.MATA    OF    THK    UTERUS. 


Ill  l"i^-.  2').')  wv  have  an  example  of  a  sul)V('sical  inyouia  encroaching  on  the 
bladder  and  greatly  diiuiiiishing  its  power  of  e<iual)le  distention.  As  it  fills,  it 
must  naturally  dilate  in  its  upjx'r  jjortion. 

fig.  2")()  shows  a  bladder  that  is  becoming  mainly  an  alxlominal  organ,  as 
Douglas'  sac  is  tilled  with  a  large  myomatous  notlule  that  has  become  incarcerated 
and  has  grown  fast  to  the  rectum. 

A  distinct  subvesical  myoma  is  not  very  connnon.  In  Ca.se  2822  the  myo- 
matous uterus  measuretl  23  x  25  cm.  There  was  also  a  subvesical  myoma,  8  x 
12  cm. 

In  Case  4832  there  was  extensive  subve.sical  development  and  several  myo- 
matous nodules. 

In  Ca.se  7226  the  bladder  was  <lrawn 
high  uj)  over  the  surface  of  a  myoma, 
about  7  cm.  in  diameter,  which  had  de- 
veloped on  the  anterior  surface  of  the 
uterus  at  the  junction  of  the  cervix  and 
l)ody. 

In  Case  lllSO  a  nodule  about  6  cm.  in 
diameter  projected  into  the  ])ladder-wall. 

It  will  thus  be  seen  that  the  develop- 
ment luider  or  the  projection  into  the 
bladder  b}'  a  myomatous  nodule  will 
materially  alter  the  shape  and  position  of 
this  viscus. 

The  Gradual  Ascent  of  the  Bladder 
with  the  Continued  Growth  of  the  Myo- 
matous Uterus. — When  the  myomatous 
development  is  in  the  upper  part  of  the 
uterus,  the  bladder  usually  remains  in  its 
normal  jjositioii,  but  if  the  growth  in- 
volves the  greater  part  of  the  uterus,  with 
the  growth  of  the  tumor  the  entire  mass 
is  forced  out  of  the  pelvis,  owing  to  the 
limited  .space,  aii<l  naturally  carries  the  bladder  with  it. 

Fig.  257  affords  a  good  illustration.  The  entire  i)osterior  wall  of  the  uterus 
is  implicated  in  the  myomatous  growth.  The  upper  ])art  of  the  tumor  has  out- 
grown the  pelvic  confines  and  stretches  high  into  the  abdomen.  The  bladder 
has  been  carried  upwai'd  on  tli(>  surfac(»  of  the  inyoiiia  uiilil  it  reaches  the  um- 
bilicus. In  such  a  case,  if  the  operator  attemi)te(l  to  open  the  abdomen  below 
the  umbilicus,  he  would  at  once  enter  the  bladder.  In  some  of  these  cases  the 
lower  limit  of  the  abdomen  is  practically  the  uiiibilicus— the  peritoneum  from 
the  abdominal  wall  being  reflecte(l  b.ack  on  to  the  tumor  at  this  point. 

The  Role  Played  by  Vesical  Adhesions. — For  marked  displacement  upward  of 
the  bladder  it  is  usually  necessary  to  have  extensive  development  of  the  tumor. 


Fig.  257. — \    Hi.addkr    Carrikd    as    High    as 

THE  Umbilicus    hy    a    Largk    Myomatois 

Uterus. 

Gyn.  No.  16S2.  The  fundus  is  recognizetl 
as  a  .slight  prominence  high  in  the  abdomen. 
The  posterior  wall  is  involved  in  a  large  myo- 
matou.s  growth,  and  the  uterine  cavity  is  greatly 
lengthenefl.  The  bladder  is  firmly  pressed 
against  the  anterior  abdominal  wall,  and  has 
been  carried  upward  on  the  surface  of  the  tumor 
as  far  as  the  umbilicus. 

The  peritoneal  reflection  anteriorly  only 
reached  the  umbilicus;  posteriorly,  the  .sacral 
prominence.  The  pelvic  portion  of  the  tumor 
was   in  reality  extraperitoneal. 

In  such  a  case  the  abdominal  incision  should 
be  commenced  well  above  the  umbilicus,  as 
there  is  great  danger  of  injuring  the  bladder. 


THK  BLADDER  IX  CASES  OF  UTEHIXE  MYOMATA. 


36i 


Init  if  the  l)la(l(ler  has  bccoinc  adherent  to  the  uterus  early,  it  may  be  carried 
upward  with  it. 


^.- 


i  ^ 


Fig.  258. — A  Bl.\dder  .\dhkrent  to  Two  Myomatous  Nodules. 
Gyn.  No.  6667.     The  body  of  the  uterus  is  occupied  by  numerous  myomatous  nodules,  and  the  round  liga- 
ments are  taut.     The  bladder  presents  a  festooned  appearance,  being  drawn    up    at   two  points    where    it    has 
become  adherent  to  small  myomatous  nodules. 


Fio.  259. — .\dhe8ions  Bktweex  the  Bi.adoer  a.nd  a  Myomatous  Uterus. 
Gyn.   No.   2777.     The  uterus  contains  several  myomata   and,  just  al)(>ve  a  larRC  siii)vesical    imdulo   which 
presses  the  bladder  against  the  symphysis,  the  bla<lder   has  become   u<lhercnt.     .Na(urall\-,  willi  the  increase  in 
the  size  of  the  tumor,  the  bladder  would  be  lifted  higher  and  highcM-. 

Fi^.  2r)S  shows  a  freely  iiio\"al)le  iiiiih  iiio(hilMr  iiiyotnalous  utei-iis.  'Hie  Mad- 
der has  become  adliei'eiit  to  two  small  myoiiiala.  ;iiid  w  illi  I  he  uiow  ili  nf  th(>se  i.s 
bein^  ^■radually  lifteil  up  inio  llie  al)d()iii('ii. 


368 


MYOMATA    OF   THE    UTERUS, 


In  Fig.  259  a  sliglitly  more  advanced  condition  is  seen.  In  the  cleft  just 
above  a  subvesical  myoma  the  bladder  has  become  firmly  adherent  to  the  myo- 
matous uterus,  and,  as  the  tumor  grows,  will  be  carried  higher  and  higher. 

Fig.  2(U)  shows  another  example  of  the  effect  of  vesical  adhesions.  Here 
almost  the  entire  anterior  surface  has  become  fixed  to  the  uterus. 

In  Case  4020  (Fig.  201)  the  l)ladder  lies  ]:>lastered  on  the  anterior  surface  of 
the  tumor,  and  can  be  lifted  well  out  of  the  abdomen. 

In  Cases  6863  and  7064  the  bladder  formed  a  complete  mantle  over  the 
anterior  surface  of  the  uterus. 

In  Case  4022  (Fig.  262)  the  bladder  was  spread  out  on  the  lower  half  of  a 
large  myomatous  uterus,  antl  large  vesical  branches  passed  to  the  tumor.     When 


Fig.  260. — Adhksions  Between  the  Bladder  and  the  Myomatous  Uterus. 
Gyn.   No.   1.3629.     The  bladder  peritoneum  is  firmly  fixed  to  the  anterior  surface  of   the  large  myomatous 
uterus.     At  one  point  is  a  sickle-shaped  opening  where  no  adhesions  existed.     The  ureters  in  this  case  were  also 
displaceii. 

the  bladder  is  intimately  adherent  to  the  tumor,  the  utmost  care  must  be  exercised 
in  freeing  it.  and  .sometimes  it  is  necessary  to  litci'ally  dissect  it  away.  In  such 
cases  if  the  bladder  be  peeled  down  with  tlH>  stalk  sponge  tluTe  is  great  danger  of 
injuring  it. 

Downward  Displacement  of  the  Bladder,  \\hen,  as  a  result  of  a  myomatous 
growth,  the  bladtler  is  displaced,  it  is  usually  carried  ujjward,  but  occasionally 
it  may  be  displaced  downward  into  the  vagina.  In  Case  4761  the  entire  pelvis 
was  choked  with  a  hard  globular  myomatous  uterus.  A  submucous  myoma, 
approximately  12  x  1")  cm.,  was  removed  through  the  vagina.  In  this  case  the 
bladder  was  displaced  downward  into  th(>  vagina,  and  micturition  and  defecation 
were  interfered  with. 


THE    BLADDER    IX    CASES    OF   UTERINE    MYOMATA. 


369 


Fig.  261. — Marked  Upward  Displacement  of  the  Bl.^ddkr. 
Gyn.  No.  4020.     Path.  No.  1009.     The  large  globular  myomatous  uterus  extended  to  within  8  cm.  of  the 
xiphoid.     The  bladder  was  adherent  to  the  tumor,  and  with  the  increase  in  size  of  the  uterus  hail  been  lifted  high 
into  the  abdomen.     (After  H.  A.  Kelly.) 


Fig.  262.— The  Bladder  l.iiii  i>  High  into  the  .\bdomk.\  hv  a  Myomatovh  I'tkhvs. 
Gyn.  No.  4022.  Path.  No.  1012.  Ttie  nodular  myomatous  uterus  extemls  upward  to  the  umbihcus.  The 
bladder  has  been  lifted  high  into  the  abdomen.  Its  upper  limits  are  clearly  indicatinl  at  the  point  at  which  the  en- 
larged and  tortuoiis  vesical  vessels  end.  For  nine  months  i)rior  to  operation  the  patient  hsu)  difficult  micturition. 
At  times  there  wa,s  stoppage  of  urine,  as  if  the  bladder  was  being  jiressc.l  upon  by  the  tumor.  (After  H.  A. 
Kelly.) 

24 


370  MYOMATA    OF   TfiK    ITKRUS. 

Condition  of  the  Bladder  "Wall  when  the  Viscus  is  Drawn  Upward  by  the 

Myomatous  Uterus. 

In  nearly  all  the  eases  the  walls  of  the  bladder,  apart  from  adhesions  on 
the  outer  surface,  were  perfeeth'  normal.  In  five  of  our  cases,  however,  some 
alteration  was  noted. 

lIyi)ertroi)hy  of  the  Uladder  wall,  4  cases. 

Hypertrophy  with  sacculation,  1  case. 

In  Case  3445  the  patient  had  frecpieiit  mietuiitioii,  and  once  it  was  necessary 
to  catheterize.  At  operation  the  bladder  reached  to  within  3  cm.  of  the  umbili- 
cus. Its  walls  were  much  hypertrophied,  thick,  and  rigid.  After  operation, 
on  account  of  the  residual  urine,  it  was  necessary  to  catheterize  almost  until  the 
time  the  patient  left  the  hospital. 

In  Case  (UTS  a  myomatous  uterus  extended  almost  to  the  umbilicus.  Mic- 
turition was  difficult  at  night,  Ijut  after  the  patient  had  been  up  and  about  during 
the  morning,  she  could  void  with  ease.  At  operation  the  bladder  was  found  to 
extend  14  cm.  above  the  symphysis.  Its  walls  were  much  thickened  and  its 
vessels  large.  "\Mien  em])tied,  it  fell  into  folds  instead  of  contracting  uniformly. 
For  four  days  after  ojoeratioii  it  was  necessary  to  catheterize. 

In  Case  6582  the  ])eKis  was  filled  with  a  retroflexed  myomatous  uterus.  For 
some  time  the  patient  had  had  frequent  micturition,  and  on  three  different  oc- 
casions during  the  previous  six  months  it  had  been  necessary  to  catheterize  on 
account  of  retention.  The  bladder  extended  half-way  to  the  umbilicus  and 
had  greatly  thickened  walls. 

In  Case  7630  a  myomatous  uterus  was  incarcerated  and  adherent  in  Douglas' 
cul-de-sac.  For  nine  months  the  patient  had  had  frequent  micturition  and 
marked  constipation  for  some  time.  The  bladdei'  was  hypertrophied  and  felt 
and  looked  like  the  body  of  a  large  uterus,  but  was  more  flabby.  When  emptied, 
it  extended  to  within  4  cm.  of  the  umbilicus. 

In  Case  11422  there  was  a  small  myomatous  uterus.  For  two  months  there 
had  been  difficulty  in  starting  the  flow  of  urine.  When  catheterized  prior  to 
ojx^ration,  the  bladder  contained  1400  c.c.  The  j^atient  was  watched  for  several 
(lavs,  and  on  no  occasion  did  she  com])letely  emj)ty  the  bladder.  At  operation 
the  bladder  was  found  well  uj)  in  the  abdomen  and  was  sacculated.  Three 
uterine  nodules,  the  largest  5  cm.  in  diameter,  were  enucleated,  and  the  round 
ligaments  shortened.  After  the  operation  a  severe  cystitis  developed.  A 
vesicovaginal  fistula  was  accordingly  matle,  and  after  the  inflammation  had 
subsided,  the  bladder  opening  was  closed. 

In  some  of  the  cases  the  myomatous  uteruf;  undoubtedly  pressed  upon  the 
bladder  and  rendered  micturition  difhcult ;  the  bladder  had  to  exert  more  force 
than  usual  and  hypertrophy  natuially  followed.  Jn  other  cases  the  liyix'itrophy 
was  an  accidental  accompaniment  of  the  myomata.  Thus,  in  Case  11422,  the 
l)ladder  condition  com])letely  overshadow(^d  the  few  symptoms  due  to  the 
relativelv  small  uterine  mvomata. 


THE    BLADDER    IX    CASES    OF    UTERIXE    MYO.MATA.  371 

Encysted  Peritonitis  Suggesting  a  Full  Bladder. 
In  Case  o()97  there  were  a  densely  adherent  and  rather  small  myomatous 
uterus  and  double  pus-tubes.  So  firmly  fixed  were  the  pelvic  structures  that  a 
I)oint  of  cleavage  was  obtained  with  the  greatest  difficulty.  L3dng  nearly  where 
the  bladder  should  have  been  was  a  pocket  that  resembled  a  full  bladder.  It  was 
noted,  however,  that  the  peritoneum  at  one  ])oint  was  especially  thin,  and  clear 
fluid  could  be  seen  immechately  beneath  it.  It  proved  to  be  a  pocket  due  to  an 
encysted  ix'i'itoiiitis. 

Injury  to  the  Bladder  During  Operation  for  Removal  of  Uterine  Myomata. 

The  injury  usually  consists  in  an  accidental  opening  into  the  bladder.  In 
many  cases  the  bladder  has  been  displaced  ujj  into  the  abdomen,  and  as  a  result 
the  operator  may  cut  through  into  this  viscus,  thinking  he  is  opening  up  the  ab- 
dominal cavity.  In  other  cases  the  bladder  has  become  intimately  adherent  to 
the  myomatous  uterus,  and  as  it  is  pushed  down  prior  to  the  hysterectomy,  it  may 
be  torn.  In  a  few  cases  the  usual  landmarks  are  lost  and  during  dissection  the 
bladder  may  be  accidentally  cut  into. 

Accidental  Opening  into  the  Bladder. — Case  1579  belongs  to  the  early  days  of 
the  hospital.  The  pelvis  was  filled  Anth  a  globular  mass,  12  cm.  in  diameter. 
During  an  exi)loratory  operation  an  incision  one  inch  long  was  accidentally  made 
into  the  bladder.  As  the  myomatous  uterus  was  firmly  fixed,  hysterectomy  was 
not  attempted.  The  bladder  opening  was  closed,  and  the  patient  recovered  with 
no  untoward  symi)toins.  Xo  ui'inary  symptoms  developed  as  a  result  of  the 
injury. 

In  Case  8437  the  uterus  contained  agloljular  myoma,  about  If  cm.  in  diameter; 
the  bladder  was  drawn  far  up,  and  as  the  abdominal  incision  was  made,  it  was 
accidentally  cut.  The  opening  was  closed  without  difficulty,  and  hyst(M-ectomy 
performed.     The  l)ladder  injury  in  no  way  retarded  the  recovery. 

Injury  to  the  Bladder  During  Hysterectomy. — In  Case  3113  there  was  a  mvo- 
matous  uterus,  a])proxiniately  2")  cm.  in  diaiiielei'.  ami  tlie  bladder  was  drawn 
high  into  the  alxlomen.  During  the  removal  of  llie  lumor  a  ])iece  of  bladder. 
3  X  (■)  cm.,  was  accidentally  bi'ought  away  with  the  tumor.  The  ureters  were  at 
once  catlieterized  thiough  the  bladder  opening,  and  this  alone  saved  ihein.  The 
bladder  was  sewed  up  immediately  with  inteii'upted  sutures  an< I  the  abdomen 
(lraine(l.     '{'here  wei'e  no  untowaid  bladder  symptoms  during  convalescc'iice. 

'i'he  inxoinatous  uterus  in  Case  ;;;;i!l  was  approximately  !,")  x  17  x  20  ciil.  and 
choked  the  pelvis.  Dui-ing  its  reinoxal  the  MaddiT  was  acci< lenlalK'  incised. 
'I'he  opening  was  clo.sed  with  catgut,  ami  the  patient  made  a  good  recovery. 

In  Case  3.")',)()  the  patient  was  lifly-nine  years  of  age  and  colored.  The  lower 
abilomen  was  markedly  distended  with  a  iiodulai-  tuinoi-  which  icached  the 
umbilicus.  An  exj)loratory  section  was  done,  and  on  account  of  the  den<e  ;u\- 
hesions  hysterectomy  was  ab.'indoned.     .\  secdiid  at  tempt  was  made  a  few  months 


372  MVOMATA    OF    THP:    UTERUS. 

later.  Although  adhesions  were  everywhere  present  and  the  heart  was  inter- 
mittent, hysterectomy  was  deemed  advisable.  During  the  enucleation  dense  ad- 
hesions were  encountered  and  the  bladder  was  accidentally  torn  for  a  distance  of 
12  cm.  As  one  ureter  lay  near  the  tear  it  was  cathcterized  and  the  l)la(l(ler  wound 
then  sewn  ui).  The  pelvis  was  drained,  anil  a  retention  catheter  left  in  the 
bladder.  The  temperature  reached  103.8°  F.  on  the  third  day.  ^^'hen  heard 
from  nearly  two  years  later  the  patient  said  she  had  been  in  perfect  health  since 
the  operation,  and  that  she  had  no  discomfort  of  any  kind. 

In  Case  3842  there  was  a  densely  adherent  myomatous  uterus  and  the  bladder 
reached  almost  to  the  umbilicus.  Dense  adhesions  existed  between  the  uterus 
and  the  bladder,  and  during  the  separation  of  the  bladder  a  piece,  1  x  G  cm.,  was 
excised  \nth  the  tumor.  The  opening  was  closed  with  mattress  sutures  of  silk. 
Intestinal  and  rectal  adhesions  were  also  present.  The  pelvis  was  drained.  The 
patient  was  discharged  on  the  thirtieth  day. 

During  the  removal  of  a  myomatous  uterus  (12  x  14  x  19  cm.)  and  double  pus- 
tubes  in  Case  5647  the  bladder  was  accidentally  opened.  It  was  at  once  sutured, 
and  a  retention  catheter  introduced.     The  patient  made  a  good  recovery. 

In  Case  6915  the  patient  was  forty-nine  years  of  age  and  had  a  very  large 
intraligamentary  myoma  on  the  left  side.  The  body  of  the  uterus  was  on  a  level 
with  the  umbilicus,  and  the  bladder  was  likewise  pushed  up  until  it  nearly  reached 
this  point.  Enucleation  was  begun  on  the  right  side,  and  the  large  mass  of 
ovarian  veins  lifted  and  tied  ^Aith  difficulty  in  the  narrow  space  between  the 
tumor  and  the  ])elvi('  brim.  After  section  of  the  right  round  ligament  the  bladder 
was  dissected  off  on  the  right  side,  revealing  a  large  mass  of  knotted  veins  going 
from  the  bladder  to  the  uterus.  The  right  uterine  vessels  were  tied,  and  the 
cervix  was  cut  across.  As  the  uterus  was  carefully  Ufted  up  there  was  suddenly 
an  almost  uncontrollable  hemorrhage.  Nothing  remained  but  to  enucleate  as 
rapidly  as  possible  in  spite  of  the  tremendous  bleeding.  With  the  uterus  partly 
rolled  out  on  the  left  side  a  large  spurting  vessel  was  caught  and  ligated.  During 
the  rapid  dissection  the  bladder  was  torn  from  the  trigonum  to  the  symphysis. 
The  opening  in  the  bladder  was  at  once  closed  with  intei-ru])ted  catgut  sutures, 
going  down  to  but  not  catching  the  mucosa.  The  highest  postoperative  tem- 
perature was  99.8°  F.  On  the  twenty-third  day  a  mild  phlebitis  developed  in  the 
left  leg;  otherwise  convalescence  was  perfect. 

In  Case  7049  a  white  woman,  aged  fifty-one,  had  an  enormous  myomatous 
uterus,  23  x  25  x  31  cm.,  with  extensive  subvesical  development.  The  bladder 
peritoneum  reached  almost  to  the  innbilicus.  The  incision  was  continued  down- 
ward to  the  symj)hysis,  but  great  care  was  exercised  to  avoid  injuring  the  l)la(lder. 
After  much  difficulty  the  left  ovarian  vessels  were  found  and  ligated.  An  attempt 
was  then  made  to  get  a  point  of  cleavage  between  the  tumor  and  the  bladder, 
but  in  doing  so  the  bladder  was  accidentally  opened  for  a  distance  of  12  cm.  on 
the  right  side.  The  dissection  was  continued;  the  right  uterine  vessels  were 
controlled  on  the  outer  side  of  the  ureter,  which  was  firmly  adherent  to  the  tumor 


THE  BLADDER  IX  CASES  OF  UTERIXE  MYOMATA.  373 

for  a  distance  of  6  cm.  It  was  now  possible  to  pass  a  finger  beneath  the  bladder, 
and  the  posterior  surface  was  thus  gradually  separated  from  the  tumor.  After 
removal  of  the  uterus  the  rent  in  the  bladder  was  closed  with  twelve  interrupted 
catgut  sutures,  extending  to  but  not  including  the  mucosa.  These  were  rein- 
forced with  a  second  row  of  catgut.  The  highest  postoperative  temperature 
was  101°  F.  on  the  fourth  day.  She  had  a  "heat-stroke"  on  the  twelfth  day, 
the  temperature  reaching  105.8°  F.     She  was  discharged  well. 

In  Case  8836  bisection  of  the  uterus  was  resorted  to  on  account  of  the  ad- 
hesions, and  as  the  patient  was  in  an  alarming  condition.  During  bisection  the 
bladder  and  rectum  were  purposely  opened.  They  were  at  once  closed  as  soon  as 
the  uterus  had  been  removed,  but  the  patient  never  rallied,  dying  a  few  hours 
later.  The  tumor  proved  to  be  sarcomatous.  The  case  is  reported  in  full  on 
p.  229. 

In  Case  10204,  while  gently  pushing  the  bladder  down  from  the  myomatous 
uterus  prior  to  doing  a  hysterectomy,  we  opened  the  bladder  for  a  distance  of  3 
cm.  It  was  at  once  sutured.  Subsequently  the  patient  developed  a  broncho- 
pneumonia.    She  was  discharged  well  on  the  forty-first  day. 

In  Case  10916  the  pelvis  and  lower  abdomen  were  filled  with,  a  myomatous 
uterus.  During  the  separation  of  many  adhesions  a  large  vein  in  the  meso- 
sigmoid  was  torn  and  profuse  bleeding  followed.  As  the  bladder  was  pushed 
down  it  was  torn  for  two  inches.  After  removal  of  the  uterus  the  tear  in  the 
bladder  was  closed  with  catgut  and  a  vaginal  drain  introduced.  The  pulse  rose 
steadily,  and  forty-eight  hours  after  operation  was  148.  The  highest  postopera- 
tive temperature  was  101.4°  F.  For  four  days  there  was  a  profuse  vaginal  dis- 
charge and  bloody  urine.     After  that  the  convalescence  was  normal. 

In  Case  11013  the  patient,  aged  forty-nine,  white,  had  first  noticed  her  ab- 
dominal tumor  fourteen  years  before  admission.  She  had  had  severe  and  pro- 
longed uterine  bleeding,  for  two  years  had  suffered  from  freciuent  urination,  and 
during  the  last  six  months  there  had  been  an  almost  constant  dribble.  The  urine 
had  a  foul  odor,  and  at  times  contained  pus.  On  admission  she  was  in  a  state  of 
chronic  invalidism.  The  pelvis  and  abdomen  as  far  as  the  ensiform  cartilage 
were  occupied  by  a  multinodular  myomatous  uterus.  During  separation  of  the 
l)ladd('r  from  the  surface  of  tlie  tumor  it  was  accidentally  opened  in  two  ))laces. 
the  ciTor  being  due  to  not  getting  the  propel"  layer  of  cleavage,  .\fter  I'einoxal  of 
the  uterus  the  bladder  openings  were  closed,  and  an  extraperitoneal  drain  in- 
troduced down  to  the  bladdei'.  The  highest  postojx'rat ive  temperature  was 
1(X).5°  F.  The  |)atient  was  si  lipid  and  rat  hei- inat  ional  toi- se\-ei'al  da\'s  al'tei' the 
opei'ation.  She  insisted  on  going  home  on  the  thirtieth  day,  aithoiigh  still  weak. 
In  ( "ase  I'JSC)!  there  was  a  \cry  large  myomatous  ulei'us  (see  p.  239). 
.\ttei"  libei'ation  of  omental  adhesions  liie  tumor  was  lifted  up  and  found  to  l)e 
lirnily  adherent  in  the  pel\is.  ( )n  ac<-ount  of  its  soft iiess  sai'coina  was  suspected. 
Satisfactory  exposure  was  impossible,  and  during  an  at  tempt  to  dissect  the  tumor 
free  on  the  left  side  the  l)ladder  was  aceideiitally  opened.     It   had  been  lifted 


374  MYO^FATA    OF    THH    X-TERUS. 

hi^h  uj)  and  Ix'cii  jjiishcd  fonvanl  by  a  retrovesical  nodule.  After  removal  of 
the  uterus  the  l)ladder  was  controlled  with  continuous  catgut  and  the  pelvis 
drained.  Th(>  ])atient  was  catheterized  at  first  every  hour.  She  was  improving 
rapidly  when  discharged  on  the  thirty-first  day. 

In  San.  Xn.  1049  the  i)atient  was  sixty-five  years  of  age  and  white.  The 
large  myomatous  uterus,  which  exteniled  almost  to  the  costal  margin,  was  firmly 
anchored  behind  to  the  rectum,  in  front,  to  the  bladder  and  anterior  abdominal 
wall.  The  tumor  was  bisected  transversely,  and  the  dense  bladder  and  ab- 
dominal adhesions  were  attacke(l  from  the  under  surface.  .Many  raw  and 
bleeding  surfaces  were  left,  and  a  hole  2  cm.  in  diameter  was  found  at  the  apex 
of  the  bladder.  This  was  closed  with  catgut.  The  large  raw  area  on  the  ab- 
dominal wall  was  ai)proximated  as  far  as  possible.  The  patient  made  a  good 
recovery.  It  is  of  interest  to  note  that  an  exploratory  oi)erati(>n  had  been  done 
thirty  years  before  and  the  case  pronounced  inoperable. 

In  the  chapter  on  Treatment  it  has  been  noted  that  few  vaginal  hysterec- 
tomies have  been  performed,  and  hence  the  bladder  injuries  complicating  vaginal 
hysterectomy  have  been  correspondingly  limited.  In  only  one  cas(>  was  the 
bladder  accidentally  opened. 

In  Case  2754,  during  reiii()\-al  of  a  small  myomatous  uterus,  the  l)aseof  the 
bladder  was  o])ened  for  4  cm.  It  was  at  once  sutured.  The  patient  comi)lained 
of  pain  in  the  bladder  for  several  days  after  operation,  but  made  a  good  recovery. 

From  our  study  of  the  relation  of  the  bladdei"  to  the  uterus  and  th(^  various 
accidents  that  ha\'e  occurred  to  it  during  hysterectomy  some  ^•aluabl(■  data  may 
be  derived : 

(a)  The  bladfler  should  always  be  carefully  ))ali)ated  with  a  catheter  while 
the  urine  is  being  withdrawn  on  the  operating  table,  to  determine  if  it  is  of  normal 
size  ()!■  not.  If  it  reaches  up  into  the  abdomen,  the  incision  should  be  made  up 
near  the  umbilicus.  After  section,  a  finger  in  the  abdomen  serves  as  a  guide  as  to 
the  location  of  the  bladder. 

(h)  In  freeing  the  bladdei'  from  tlie  uterus  very  little  force  should  be  used 
with  the  stalk  sponge,  and  if  it  seems  fixed,  it  is  better  to  carry  out  the  dissection 
with  the  knife,  the  cutting  edge  being,  of  course,  directed  toward  the  tumor  and 
not  toward  the  bladder. 

(c)  After  all  hysteromyomectomies  it  is  imj)oi-tant  to  carefully  examine  the 
bladder  and  rectum  to  see  if  they  have  been  injui'ed. 

(d)  If  the  bladdei'  is  accidentally  opened,  the  tear  iiia>"  be  closed  with  inter- 
rupted or  continuous  catgut  sutures,  catching  uj)  all  but  the  mucosa.  This  row 
of  sutures  should  be  coxcrcd  in  with  a  continuous  line  Pagenstecher  or  silk  suture. 
The  greatest  care  imist  be  exercised  not  to  pierce  the  vesical  mucosa,  as  the 
suture  might  form  the  nidus  for  a  sul)se(jueiit  calculus.  If  the  tear  be  near  the 
ureter,  it  is  wise  to  outline  clearly  the  ureter  by  means  of  a  ureteral  catheter  while 
the  sutures  are  being  introduced;  and  if  the  ureteral  orifice  is  too  close  to  the 
incision,  a  slit  1  cm.  long  may  be  made  in  it. 


THE    BLADDER    IX    CASES    OF   UTERINE    MYOMATA.  375 

(e)  As  injuries  of  the  blatlder  ure  usually  associated  with  dense  pehic  ad- 
hesions, it  is  frequently  advisable  to  drain  through  the  vagina. 

(/)  We  realize  the  shortcomings  of  a  retention  catheter,  hut  notwithstanding 
its  tlrawl)acks,  we  unhesitatingly  reconnnend  its  use  for  the  fii'st  two  or  three 
days  in  cases  in  which  the  bladder  has  l)een  accidentally  opened. 

{(J)  Injury  to  the  bladder,  if  recognized  and  attended  to,  does  not  materially 
increase  the  risks.  In  only  one  of  our  cases  did  death  follow,  and  here  the  fatal 
issue  was  due  to  innnediate  shock. 

Injuries  to  the  bladder  are  bound  to  occur,  es])ecially  in  the  presence  of 
dense  adhesions,  where  the  viscus  is  displaced,  and  we  deem  ourselves  fortunate 
that  this  accident  has  not  befallen  us  more  freciuently.  In  desperate  cases,  when 
the  patient  is  exceedingly  weak  or  when  alarming  hemorrhage  is  going  on,  the 
speedy  removal  of  the  uterus  is  infinitely  more  important,  even  if  the  bladder  is 
injured,  than  a  careful  dissection  of  the  bladder  with  the  collapse  and  probable 
death  of  the  patient  before  the  operation  is  completed.  As  our  class  of  myoma 
cases  is  becoming  more  and  more  difficult  each  year,  we  nnist  naturall}^  expect 
a  continuance  of  a  certain  number  of  injuries  to  the  l)ladder. 


Hysteromyomectomy  with  the  Subsequent  Passage  of  a  Silk  Ligature  from  a 
Uterine  Artery  into  the  Bladder. 

Case  F.,  seen  in  consultation  with  Dr.  A.  Trego  Shertzer  at  the  Church  Home 
and  Infirmary,  August  10,  1902.  The  operation  was  very  difficult.  Thei-e  was 
a  very  large  strangulated  umbilical  hernia  and  a  huge  myomatous  uterus  with  its 
lower  portion  molded  to  the  pelvis  (Fig.  94,  p.  120).  The  patient  made  a  good 
recovery. 

Months  after  she  l)rought  to  one  of  us  fCullen)  a  small  loop  of  thread  which 
she  had  just  passed  from  the  bladder.  It  was  a  silk  ligature  from  one  of  the 
uterine  art(Ties.  The  loop  was  perfect,  and  the  two  ends  of  the  ligature  were 
intact.  The  ligature  had  e\idently  lain  in  the  bladder  some  little  time,  as  it  was 
partly  incrusted.  The  stunij)  of  one  of  the  uterine  arteries  had  evidently  lain 
in  contact  with  the  bladder,  and  the  ligature  had  gradu;dly  worked  its  way 
through.     It  had  occasioned  the  patient  little  or  no  incon\-enieiice. 

A  Vesical  Calculus  Associated  with  Uterine  Myomata. 

Vesical  calculus  was  noted  in  only  one  instance.  In  Case  .")9I()  tlie  patient, 
aged  fifty-two,  white,  had  a  lai'ge  myomatous  uterus  whidi  almost  lillc(l  the  ab.- 
domen.  For  the  ])revious  year  she  had  had  attacks  of  pain  in  the  bladder  and 
fre(|uent  mict  ui'ition,  licniat  ui'ia,  tenesmus,  and  sudden  slo|i|)age  ot  urine.  The 
vesical  symjitoms  had  been  almost  continuous  for  the  nine  weeks  pi'ioi-  to  opei'a- 
tion. 

A  catheter  introduced  into  the  blaijdei'  at  once  came  in  contact  with  a  cal- 
culus.    An  attempt    was  made  to  reinoxc  the  stone  tlii-ough   the  urelhia,  but    it 


376  MYOMATA    OF   THK    ITKRIS. 

was  foiiiul  necessary  to  extract  it  throujili  a  vesicovaginal  incision.  The  opening 
was  at  once  closed,  and  a  retention  catheter  introduced.  Recovery  was  satis- 
factory. 

Bladder  Symptoms  Attributable  to  the  Myomata. 
In  the  u;reater  nuniher  of  the  cases  the  patient  gives  no  history  suggestive  of 
bladder  disturbance.     In  a  certain  small  percentage,  however,  definite  vesical 
symptoms  are  present.     These  and  theii-  older  of  frequency  may  be  stated  as 
follows : 

1.  Frecjuent  urination. 

2.  Frequent  and  painful  uiination. 

3.  Retention  of  urine. 

4.  Loss  of  control. 

Frequent  urination  is  the  most  common  bladder  sym])tonL  It  is  evidently 
due,  in  many  instances,  to  the  encroachment  of  the  myomatous  uterus  upon  the 
bladder,  which  necessitates  the  more  frecpient  emj)tyiiig  of  this  viscus.  This 
increased  frequency  in  micturition  differs  entirely  from  that  due  to  cystitis.  In 
many  cases  there  is  absolutely  no  pain,  and  getting  up  at  night  to  void  is  most 
uncommon.  Out  of  109  cases  in  which  there  was  frequent  and  painful  micturi- 
tion, only  f)  of  the  patients  had  to  rise  at  night. 

Frequent  and  Painful  Urination. — There  is  often  a  feeling  of  discomfort  or 
weight,  rather  than  ))ain,  in  the  bladder  during  micturition.  Some  patients, 
however,  have  definite  vesical  pain  and  tenesmus  when  voiding.  The  pain  is 
evidently  due  to  the  fact  that  the  tumor  pushes  the  two  bladder-walls  together, 
and  in  those  cases  in  which  the  bladder  has  become  adherent  to  the  tumor  and 
has  been  draw^n  far  up  into  the  abdomen,  it  is  impossible  for  it  to  contract  prop- 
erly and  satisfactorily  empty  itself.     This  naturally  tends  to  produce  tenesmus. 

Retention  of  Urine. — In  20  cases*  partial  or  complete  stoppage  of  urine  was 
noted.  Sometimes  there  was  difficulty  in  starting  the  flow,  as  in  Case  10991; 
in  others  .sudden  obstruction,  as  in  Case  12293.  In  Case  13016  there  was  acute 
obstruction  for  twenty-four  hours.  In  Case  2073  catheterization  was  also  neces- 
sary. The  retention  is  undoubtedly  due  to  the  tumor  shifting  in  such  a  manner 
that  the  urethra  or  bladder  is  so  jammed  against  the  symphysis  that  escape  of 
urine  is  impossible.  The  stoj^page  of  urine  rarely  lasts  over  twenty-four  hours. 
It  may  be  periodic,  as  in  Cases  oK)  and  9057.  When  the  tumor  has  passed  high 
into  the  abdomen,  the  tendency  to  retention  is  diminished. 

Loss  of  Control. — In  Cases  7063,  7583,  979S  the  patients  had  a  feeling  of  pres- 
sure on  the  bladder  or  had  frecpient  micturition,  and  at  times  great  difficulty  in 
preventing  the  urine  from  dribbling  out. 

In  Cases  1039,  3133,  5421,  and  11587  there  was  at  times  complete  loss  of 
control.  In  each  of  the  7  cases  the  ))ressure  of  the  tumor  on  the  bladder  seemed 
to  be  the  cause  of  the  disturbance. 

♦Retention  was  noted  in  Cases  516,  149.5, 1499,  1716,  2073.  3038,  4022,  4168,  5332,  5987,  6854, 
6992.  9057,  9612,  10969.  10:)ni,  121.')4.  122.")7.  12293.  and  13016. 


THE  BLADDER  IK  CASES  OF  UTERINE  MYOMATA.  377 

Cystitis  Associated  with  Uterine  Myomata. 

Despite  the  fact  that  the  liladder  may  l)e  displaced  and  altered  in  its  shape  by 
the  myomata,  vesical  inflanunation  is  rarely  found.  In  only  two  of  our  cases 
was  it  particularly  prominent. 

In  Case  4599  there  was  a  marked  cystitis  on  admission,  and  in  Case  11013  a 
constant  dribble  of  offensive  urine. 

The  fact  that  the  bladder  mucosa  is  usually  normal  in  myoma  cases  has  a 
definite  surgical  import.  If  the  bladder  be  accidentally  opened,  we  know  that 
if  it  be  properly  sutured  the  accident  has  in  no  way  increased  the  tendency 
toward  infection. 


CHAPTER  XXI. 
THE  URETERS  IN  CASES  OF  UTERINE  MYOMATA. 

1.  Position. 

2.  Double  urctci". 

3.  Pressure  on  the  ureters. 

4.  Accidental  liti'ation. 

5.  Injury  to  the  ureter  (lurin.ii-  operation. 

6.  Removal  of  a  tubei-culous  kidney  and  ureter  shortly  after  hysteromyo- 
niectoniy. 

7.  Locating  th(^  ureters  during  operation. 


Position  of  the  Ureters  in  Cases  of  Uterine  Myomata. 
When  uterine  myomata  spread  out  from  the  surface  of  the  uterus  and  lie  free 

in  the  abdominal  cavity,  as  a  rule,  little  anxiety  need  be  felt  about  the  ureters, 

l)ut  if  an  interstitial  myoma  spreads 
out  between  the  folds  of  the  broad 
ligament,  the  ureter  may  be  dis- 
lodged, and  at  times  lie  on  the  sur- 
face of  the  tumor.  A  similar  con- 
dition is  occasionally  noted  when 
cerx'ical  myomata  reach  large  pro- 
portions. 

Fig.  203  shows  a  splendid  example 
of  a  dilated  ureter  which  has  been 
lifted  up  with  the  pelvic  peritoneum 
and  lies  on  the  side  of  the  tumor. 
Were  the  operator  not  on  his  guard, 
the  vessel  might  very  readily  be  mis- 
taken for  a  lymphatic  and  clamped 
and  tied.  In  this  case  (Gyn.  No. 
2809)  the  whole  abdomen  was  filled 
with  a  nuiltinotlular  myomatous 
uterus.  The  tubes  and  ovaries  were 
drawn  up  high  on  either  side.  Both 
ureters  were  lifteil  high   out  of  the 

pelvis.     The  left    ureter  was   ligated,   but    not    cut.     Later,    the  mistake  was 

recognized  and  the  ureter  liberated.     The  ureter  on  the  right  .side  was  detected 

early  in  the  enucleation  and  was  not  injured. 

378 


Fig.  263. — Dislocation  and  Dilatation  of  a  Ukktkr 
DUE  TO  A  Large  Myomatous  Uterus. 

Gyn.  No.  2899.  Only  a  small  part  of  the  uterus, 
which  filled  the  entire  abdomen,  is  seen.  To  the  right 
is  the  right  round  ligament.  The  right  ureter  is  much 
filiated,  and  was  displaced  so  high  that  a  portion  of  it  was 
brought  out  of  the  abdomen  with  the  tumor.  It  might 
readily  have  been  mistaken  for  a  dilated  lymi)hatic  vessel 
(see  Fig.  .57,  p.  7.3)  and  severed.  The  congeries  of 
vessels  just  above  the  loop  of  the  ureter  are  the  ovarian 
vessels. 

Both  ovaries  and  the  left  ureter  were  also  lifted  high 
into  the  abdomen. 


THE    URETERS    IX    CASES    OF    UTERIXK    MYo.MATA. 


379 


lifted  upward  and  forward,  and  crosses  just   at   the  point 
where  one  would  naturally  tie  the  right  ovarian  vessels. 


In  Case  3133  the  abdomen  was  tilled  with  a  myomatous  uterus.  The  fundus 
lay  near  the  ribs  in  the  median  liiu\ 
The  l^ladder  rose  S  cm.  above  the 
symphysis,  and  the  ovarian  veins 
were  greatly  distended.  The  sig- 
moid was  adherent  to  the  tumor, 
about  S  cm.  above  the  pelvic  brim. 
After  this  had  been  freed,  the  left 
ovarian  vessels  were  ligated.  The 
left  ureter  was  found  adherent  to 
the  posterior  surface  of  the  tumor,  fig.  264.— a  m^..ma  in  ihk  bkoau  li(;amknt  displac- 
and  was  freed.    The  left  uterine  ves-         ^'^^  '^^'^  ^^^"'^  ^'^^''™  ^^'^•'^"  -'^^  fobward. 

Gyn.  No.  3971.     Occupying  the  right  broad  ligament 
Sels    were    then     ligated.       The     right         is  a  laVge  myomatous  nodule.     The  right  ureter  has  been 

ureter  as  it  entered  the  broad  liga- 
ment was  compressed,  and  its  upper 
portion  was  about  2  cm.  in  diameter.      It  was  dissected  down  to  the  bladder. 
Fig.  2(34  shows  the  altered  position  of  the  ureter  due  to  a  broad-ligament 

myoma.  In  this  case  (Gyn. 
No.  3971)  it  was  so  situated 
that  it  might  readily  have 
been  tied  with  the  right 
ovarian  vessels. 

In  Fig.  265  (Case  6017) 
we  see  the  bladder  and  left 
ureter  lifted  high  up  by  a 
myoma  which  filled  the 
p(>l\'is  and  rcachcil  to  the 
umbilicus.  I'lic  ureter  was 
recognized  and  carefully 
freed. 

In  Case  9  I."  the  uterus 
was  the  s(v\t  of  ;i  diffuse^ 
;ideiiomyoiii:i  and  the  right 
o\'ary  was  i-ejilaeeil  by  a 
large  cyst  eoiit.'iiniiig  can- 
cerous ai'eas.  l".;ieh  ureter, 
aftei'  i>assiiig  o\-ei'  the  |)el\ic 
bi'iiii.  r.aii  almost  a  str.aight 
course  to  a  i)oiiil  near  the 
coi'respondiiig  uterine  horn. 
Both  urelei's  were  dissected 
le    I'einowd    of    the    litems 


Fig.  265. — Dislocation  Upward  and  Forward  of  tiik  Lkit  Urk- 
TKR  BY  a  Myomatous  Utkrus. 

Gyn.  No.  6017.  The  myomatous  uterus  reaches  the  uinhiliciis, 
and  the  greatly  lengthened-out  uterine  cavity  can  be  traced  by  tlir 
dottefl  lines  to  the  vagina. 

The  left  ureter  pa.sses  over  the  surface  of  the  tmnor  at  the  level 
of  the  pelvic  lirim,  and  is  inserted  into  the  bl.adder,  which  is  lifted  high 
up  into  the  abdomen.      In  reality  it  docs  not  enter  the  ix'lvi-  al  all. 


free  for  a  distance 
was  bemm. 


S    to    10   cm.    before   ll 


380 


MYOMATA    OF    THE    UTERUS. 


Fig.  266  shows  a  ureter  j^assing  directly  across  from  the  pelvic  brim  to  the 
bladder  without  di{)ping  into  the  pelvis. 

Dislocated  ureters  were  also  iiottxl  in  Cases  3281,  4168,  and  8391.  This  by 
no  means  represents  the  total  number,  but  only  those  especially  mentioned  in 
the  notes  made  at  operation. 

Dr.  J.  H.  Mason  Knox,*  in  1000,  ))ublished  an  excellent  article  on  the  effect  of 


Fund  ul. 


r    TopofWadd 


^     <-^ /"  Lpening  of  ureter 
Cervix 


Fig.  266. — Marked  Di.si.oc.vtiox  ok  the  Ureters  Where  the    .\bdomen  was    Filled  with  a    Myomatous 

Uterus. 

The  fundus  is  situated  high  in  the  abdomen,  and  the  right  ureter  is  seen  plastered  on  the  surface  of  the  tumor. 
Starting  near  the  fimbriated  end  of  the  tube  is  the  peritoneal  reflection.  This  can  be  followed  backward  to  a 
point  a  short  distance  above  the  sacral  prominence,  .\nteriorly,  it  reaches  a  little  below  the  umbilicus;  thus  more 
than  half  of  the  tumor  is  extraiieritoneal. 

The  blatlder  is  raised  high  up,  and  the  right  ureter  passes  directly  across  the  pelvic  brim  to  the  bhadder.  The 
left  ureter  is  seen  at  a  slightly  higher  level,  as  indicated  by  the  dotted  lines. 

This  operation  was  rendered  more  difficult  from  the  fact  that  the  lower  portion  of  the  myoma  filled  the  pelvis 
so  snugly.     (After  Howard  A.  Kelly.) 


pressure  of  myomata  on  the  ureters,  and  discu.ssed  fully  most  of  those  cases  that 
had  been  observed  in  the  g}'necological  department  of  the  Johns  Hopkins  Hos- 
pital prior  to  that  date. 

*  J.  H.  Mason  Knox,  Compression  of  the  Ureters  by  Myomata  Uteri,  Amer.  Jour.  Obst.,  1900. 
vol.  xlii,  No.  4. 


THE    URETERS    IX    CASES    OF    UTERINE    MYOMATA. 


381 


Double  Ureter. 
In  case  C.  H.  I.  949,  while  dissecting  out  the  left  ureter,  we  found  two  ureters 
instead  of  one.  They  ran  side  by  side  to  within  about  1.5  cm.  from  the  bladder, 
and  then  entered  the  bladder  as  a  single  ureter.  It  is  well  to  bear  in  mind  the 
possible  existence  of  a  double  ureter.  If  there  is  a  double  ureter  and  one  is 
ligated,  the  portion  of  the  kidney  connected  with  the  ligated  ureter  will  naturally 
be  thrown  out  of  function. 


Pressure  on  the  Ureters  Exerted  by  Uterine  Myomata. 

In  Chapter  XXIII  (p.  396)  we  have  described  the  condition  of  the  ure- 
ters in  cases  of  uterine  myomata  coming  to  autopsy.  Here  we  will  briefly  refer 
to  the  deviations  from  the  normal  noted  at  operation. 

Before  performing  an  abdominal  hysteromyomectomy  the  urine  is  carefully 
examined,  and  if  any  marked  evidence  of  renal  infection  exists,  when  possible, 
operation  is  avoided.     Consequently,  we  would  not  expect  to  find  any  serious 
alterations   in    the   ureters    in    the 
operable  cases. 

As  a  result  of  the  pressure  of  the 
myoma,  one  or  both  ureters  may  be 
so  flattened  or  kinked  that  above 
the  point  of  obstruction  a  hydro- 
ureter  develops.*  In  our  experience 
the  right  ureter  is  more  frequently 
implicated  than  the  left.  In  a  few 
cases,  as  in  No.  2899  (Fig.  267)  and 
8391,  both  ureters  were  dilated. 

The  obstruction  may  be  in  the 
pelvis  or  just  at  the  pelvic  brim. 
The  size  of  the  ureter  will  depend, 
of  course,  on  the  degree  of  obstruc- 
tion. It  may  be  twice  its  natural 
size,  as  in  Case  6418;  it  may  reach 
1.3  cm.  in  diameter,  as  in  Case  7597, 
or  1.8  cm.,  as  in  Case  8391.  Occa- 
sionally the  size  may  be  enormous, 
as  in  Case  10204,  in  which  the  left 

ureter  above  the  jx'h'ic  bi'iiii  foniicd  a  sac  4  ciii.  in  (liaiiictci-.  Sudi  a  large 
ureter  may  at  first  be  mistaken  for  a  loop  of  small  liowcl,  l)ul  il  has  no  mesen- 
tery, has  thin  walls,  and  contains  transparent  fluid. 


Fig.  267. — Hydroureter  Due  to  Pressure. 

Gyn.  No.  2899.  The  abdomen  was,  to  within  4  or  5 
cm.  of  the  ensiform  cartihiRe,  lille<l  with  a  hard  myoma- 
tous uterus.  Botli  ureters  were  lifted  high  out  of  the 
pelvi.s.  The  left  was  accidentally  tied,  but  later  discov- 
ered and  released. 

The  sketch  shows  the  pelvis  after  removal  of  the 
uterus.  The  right  ureter  is  markedly  dilated;  the  left 
also  to  a  limited  degree. 


*  Hydroureter  was  noted  in  Cases  2708,  2899,  3426,  4020.  (ills,  T.y.V, 
and  10462. 


'M7.  7s;v2,  s;iin.  10204. 


382  MVOMATA    OF    THE    UTERUS. 

Accidental  Ligation  of  the  Ureter  During  Hysteromyomectomy. 

A\'c  liave  recoiils  of  several  cases  in  which  one  ureter  was  accidentally  tied, 
oitiicr  when  the  utorino  artery  was  being  controlled  at  the  side  of  the  cervix  or 
when,  owing  to  marked  (lisj)laceinent,  the  ureter  lay  close  to  the  point  at  which 
the  ovarian  ve-^sels  were  ligated. 

In  Case  659  a  large,  densely  adherent  cystic  myoma  filled  the  abdomen.  It 
was  impossible  to  remove  the  growth,  but  the  ovarian  and  uterine  vessels  on  both 
sides  wereligatefl.  The  patient  did  fairly  well  after  the  operation,  but  died  sud- 
denly on  the  eighth  day.  Aut.  No.  188  showed  a  very  large  cystic  myoma  and 
general  anemia;  one  kidney  was  the  seat  of  hydronejjhro.^is,  the  other  of  pyelo- 
nephi-osis  with  renal  abscesses.  The  left  uretcn-  was  occluded  by  a  ligature.  The 
abdominal  condition  was  in  itself  suHicieiit  to  cause  the  fatal  issue.  l)ut  death  was 
undoubtedly  hastened  by  tlie  accidental  ligation  of  the  ureter. 

In  Case  2899  the  entire  abdomen  was  filled  with  a  myomatous  uterus.  The 
tubes,  ovaries,  and  ureters  were  lifted  high  out  of  the  pelvis.  Both  ureters  were 
dilated.  The  left  was  acci(l(>ntally  ligated.  but  the  error  was  later  discovered, 
and  the  ureter  was  rc^leased.     The  jiatient  recovereih 

In  Case  3272  a  globular  myomatous  uterus  filled  the  i)elvis.  The  right  ureter 
was  tied.  Later,  the  .mistake  was  discovered  and  the  ureter  released.  The 
patient  recovered. 

During  the  removal  of  a  large  myomatous  uterus  complicated  by  an  ovarian 
cyst  in  Case  6344  (Fig.  242,  )).  347)  the  left  ureter  was  accidentally  included  in  the 
ligature  controlling  the  left  uterine  vessels.  After  I'emoval  of  the  uterus  the  left 
ureter  was  located  at  the  pelvic  brim,  and  followed  down  to  the  cervix.  After 
the  ureter  had  been  freed,  the  uterine  vessels  were  retied.     The  i^atient  recovered. 

In  Case  8321  the  myomatous  uterus,  which  filled  the  jielvis,  was  removed 
from  left  to  right.  During  ligation  of  the  right  uterine  artery  the  ureter  was 
included.     The  error  was  discovered  and  rectified.     The  patient  recovered. 

In  C.  H.  I.  R..  ()ctol)er  24,  1902,  the  patient  was  very  anemic.  The  pelvis 
was  filled  with  a  inultino(hilar  myomatous  uterus,  and  ()ccuj)ying  the  vagina  was 
a  large  gloljular  submucous  nodule.  On  the  right  side  the  ovarian  vessels  were 
controlled  with  the  utmost  difficulty  on  account  of  their  distorted  position.  After 
removal  of  the  uterus  the  right  ovarian  .'^tump  was  examined  and  the  ureter  found 
included  in  the  ligature.  It  was  released  without  much  (HHicu.lty,  and  the  j)atient 
made  a  perfect  recovery. 

From  the  forc^going  we  see  that  in  only  one  case  did  we  fail  to  discover  the 
ligated  ureter  before  the  abdomen  was  closed.  In  this  case  death  followed. 
Temporary  ligation  does  not  seem  to  matei'ially  injure  the  ureter. 

Injury  to  the  Ureter  During  Hysteromyomectomy. 
In  two  of  our  cases  the  ureter  was  accidentally  cut  during  the  hysteromyo- 
mectomy.    In  both  cases  a  uretero-ureteral  anastomosis  was  done,  in  one  case 
with  failure,  in  the  other  with  success. 


THE    I'RETEKS    IX    CASES    OF    UTERINE    .MVOMATA. 


383 


Gyn.  No.  11989. 

H  y  s  t  e  r  0  m  y  o  111  0  c  t  o  m  y  ;  accidental  e  u  t  t  i  n  ,«;  o  f  t  li  e 
left  ureter;  u  r  e  t  e  r  o  -  u  r  e  t  e  r  a  1  a  11  a  s  t  o  111  o  s  i  s  ;  failure; 
subsequent     r  e  ni  o  \'  a  1    of    the     left     k  i  d  n  c  3^  ;      recovery. 

R.  R.,  wliite.  aged  thirty-five.  Admitted  March  23,  1905.  For  several 
years  she  had  had  frequent  urination  and  had  Ijeen  forced  to  get  uj)  several  times 
at  night  to  void.     There  had  been  pain  and  pressure  over  the  bladder. 

During  the  I'emoval  of  the  myomatous  uterus,  which  reached  to  tlie  um- 
bilicus, the  left  ureter  was  cut.  The  ureter  was  at  once  anastomosed  into  itself, 
and  an  extraperitoneal  drain  carried  down  to  the  ureter. 

On  the  day  following  it  was  evident  that  the  urine  from  the  left  kidney  was  not 
reaching  the  l)lad(ler.  and  as  none  escaped  along  the  extraperitoneal  drain,  the 
vaginal  vault  was  opened,  nitrous  cxid  anesthesia  being  emijioyed.     A  small 


Fig.  2fiS. — Displaced  Ricnr  I'rktkr  Mistaken  for  a  Dit.ated  Vein;  Ligated  and  Cut;  Successful  Enu-to- 

siDE  Anastomosis. 

Gyn.  No.  1946.  The  dotted  line  indicates  the  course  of  the  uterine  cavity.  The  right  ureter  had  been  lifted 
high  on  the  .side  of  a  myomatous  nodule,  and  being  mistaken  for  a  vein,  was  ligated  and  cut. 

a  indicates  one  of  the  two  traction  sutures  by  means  of  which  the  upper  end  of  the  ureter  was  drawn  down 
into  the  slit  on  the  side  of  the  lower  end  of  the  ureter  and  held  in  place  until  the  ten  approximation  sutures  had  been 
introduced  and  tied.  The  traction  sutures  were  then  removed  as  they  entered  the  lumen  of  the  ureter,  and  later 
might  have  become  incrusted. 

amount  of  blood-tinged  fluid  escaped.  The  jiatient  gradually  improved.  An 
(ether)  examination  revealed  the  fact  that  the  fistulous  tract  leading  from  the 
previous  ureteral  anastomosis  had  made  its  way  down  and  out  through  the 
stiim|)  of  the  cervix. 

It  was  thought  that  it  might  be  possil)le  to  go  in  extraperitoneally  and 
reanastomose  the  uretei'.  There  was,  howe\'er.  too  much  jxTi-iireteritis  lo 
warrant  such  a  j^rocedure.  The  urine  from  the  hl.-idder  and  fi'oiii  the  ih'ainage 
tract  had  been  carefully  exainine(l  for  urea.  Il  was  found  that  ihe  ligiit  ki(hie>" 
was  secreting  from  1000  to  ]2()()  c.c.  with  about  10  gm.  of  urea  lo  the  htei-.  This 
was  thought  sufhcient  to  allow  the  i-eiiio\al  of  ihe  lel'l  ki(hie\-.  and  as  the  |»alient 
refused  to  go  home  and  wait  for  two  oi-  thi-ee  months  to  see  if  the  listulous  tract 
would  close  of  its  own  accoi'd,  remo\al  of  the  h'ft  kidney  was  uuih'i'takeii.  The 
highest  postoperative  temperature  was  100°  V..  ;ind  the  patient  made  a  good 
recovery. 


384  MYO.MATA    OF   THE    UTERUS. 

Gyn.  No.  1946. 

A cci dental  severance  of  the  displaced  right  ure- 
ter during  h  y  s  t  e  r  o  ni  y  o  m  e  c  t  o  m  y  .  Successful  u  r  e  t  e  r  o  - 
ureteral    anastomosis  (Fig.   268). 

F.  M.,  aged  twenty-five,  colored.  Admitted  April  26;  discharged  June 
13,  1893.  During  the  removal  of  a  large  myomatous  uterus  what  appeared  to 
be  a  large  vein  on  the  right  side  was  ligatetl  and  cut,  when  it  was  found  to  be  the 
ureter.  The  upper  end  of  the  ureter  was  invaginated  into  the  opening  made  in 
the  side  of  the  lower  portion,  the  invagination  being  accomplished  by  means  of 
two  temporary  sutures  (Fig.  268).  Accurate  approximation  was  now  obtained 
with  ten  tine  silk  sutures.  A  gauze  drain  was  inserted  in  the  pelvis  and  the 
patient  made  an  uiiintcrrujjted  recover}'. 

Removal  of  a  Tuberculous  Right  Kidney  Shortly  after  a  Hysteromyomectomy. 
The  following  case  .shows  clearh'  what  extensive  operations  even  a  weak 
patient  may  be  able  to  stand. 

Gyn.  No.  12866.     Path.  No.  9755. 

L.  T..  aged  thirty-nine,  white,  married.  Admitted  April  23;  discharged 
July  26,  1  *)()().  The  ])atient  entered  the  hospital  complaining  of  pain  in  the 
bladder,  rectum,  and  back. 

Three  years  before  she  had  been  under  treatment  on  the  surgical  side  of  the 
hospital  for  tuberculosis  of  the  right  hip.  At  that  time  the  joint  was  aspirated 
and  a  cast  was  put  on.     She  remained  in  the  hospital  for  three  months. 

Urination  had  been  very  fre([uent  and  painful  for  the  last  year,  and  there  was 
much  vesical  tenesmus  after  voiding. 

Cystosco])ic  examination  revealed  extensive  ulceration  of  the  vertex  pos- 
teriorly, and  also  on  the  right  side.  The  right  ureteral  orifice  was  nmch  reddened. 
The  left  ureteral  orifice  w^as  retracted,  and  from  it  pus  was  exuding. 

On  jx'lvic  examination  the  right  ureter  was  palpable,  hard,  and  {prominent. 
A  hrmly  fixed  myomatous  uterus  filled  the  pelvis. 

On  section  of  the  abdomen  the  omentum  was  found  adherent.  Many  ad- 
hesions were  found  in  the  region  of  the  cecum,  and  several  small  tubercles  were 
detected  on  the  cecum  and  scattered  over  the  loops  of  small  bowel  in  the  vicinity. 
The  appendix  was  not  seen.  After  much  difficulty  the  adluTcnt  uterus  with  its 
appendages  was  removed. 

The  right  ureter  was  much  thickened  and  indurated.  The  right  kidney  was 
movable,  and  about  twice  its  natiu'al  size.  The  liver  was  fixed  to  the  anterior 
abdominal  wall.  The  left  kidney  was  normal  in  size.  The  tuberculous  process 
in  the  abdomen  seemed  to  be  limited  to  the  right  iliac  fossa. 

Path.  No.  9755.  Examination  of  the  pelvic  contents  revealed  interstitial 
and  submucous  uterine  myomata,  tuberculosis  of  the  endometrium,  tuberculosis 
of  both  tubes,  and  general  pelvic  peritonitis. 


THE    URETERS    IX    CASES    OF   UTERIXE    MYOMATA.  385 

Right  Nephrectomy  , — Thirty-six  days  after  the  hysteromyomectomy 
the  right  kichiey  was  removed,  the  sufficiency  of  the  excretion  from  the  left 
kidney  in  the  meantime  having  been  fully  established. 

When  the  patient  left  the  hospital,  the  okl  sinus  at  the  hip  had  not  yet  en- 
tirely healed.  The  bladder  mucosa,  although  still  red  and  showing  many  tu- 
bercles and  some  areas  of  superficial  necrosis,  was  considerably  improved. 

Location  of  the  Ureters  During  Hysteromyomectomy. 

The  one  question  that  haunts  the  operator  most  after  difficult  hystero- 
inyomectomies  is:  Have  I  tied  one  or  both  ureters?  With  the  gradual  develop- 
ment in  the  operative  technic  the  operation  has  become  not  only  easier,  but  also 
more  simple,  and  if  the  operator  is  in  the  least  worried,  he  can  answer  his  question 
at  once  before  the  abdomen  is  closed.  We  now  make  it  a  rule  to  examine  care- 
fully the  ureters  in  any  case  in  which  there  is  the  slightest  possibifity  that  they 
have  been  injured. 

In  some  of  our  early  cases  the  ureters  were  catheterized  prior  to  operation. 
In  the  first  place  this  is  a  doubtful  procedure,  since  a  foreign  body  in  the 
ureter  for  a  half  to  an  hour  or  more  may  cause  injury  to  it,  and,  in  the  second 
place,  because  in  the  very  cases  in  which  we  most  desire  to  outline  the  course  of 
the  ureters,  they  are  so  displaced  and  distorted  by  the  myomata  that  catheteriza- 
tion of  them  is  almost  impossible. 

One  of  us  (Kelly)  years  ago  noticed  the  vermicular  contraction  of  the  ureters 
on  manipulation.  We  accordingly  gently  stroke  the  peritoneum  at  the  pelvic 
brim,  just  where  the  ureter  should  be,  with  a  pair  of  blunt  forceps,  and  the  ureter 
will  usually  be  seen  to  begin  its  snake-like  contraction.  It  is  then  dissected  out 
down  to  the  cervix,  care  l)eing  taken  not  to  loosen  it  from  its  j)eritoneal  cover- 
ing, as  its  blood-supply  might  be  interfered  with.  This  point  has  been  very 
clearly  brought  out  by  Sampson.* 

The  opposite  ureter  is  then  exposed  in  the  same  way. 

One  of  us  (Cullen)  found  it  necessary  to  isolate  the  ureters  in  this  maimer  in 
three  cases  in  a  single  moining. 

Occasionally,  a  fold  of  pei'itoneum  may  simulate  a  ureter,  but  it  lacks  the 
vermicular  contraction  and  is  not  covei'ed  with  the  delicate  tracery  of  \'e.ssels  so 
characteristic  of  the  ureter. 

Sometimes  the  peritoneum  of  the  jx'lvis  over  the  ureter  has  become  densely 
adherent  to  the  myoma,  as  in  Case  7()4!>,  oi'  to  an  accoui]ianying  cyst,  as  in  Case 
71S1.  It  is  then  liable  to  be  much  tliickeiieil.  and  detection  of  the  ureter  is  luucli 
more  difficult. 

If  the  operator  is  unable  to  locate  the  ureter  and  feels  i-el;iti\-el\-  sure  that  it 
has  been  tied,  as  a  last  resort  he  can  split  the  M.adiler  ;tud  iuti-oduce  a  renal 
catheter  through  the  ureteral  orilice.  This  will  not  lengthen  the  oju'ration  over 
fifteen  or  twenty  minutes,  and  may  be  a  life-saving  procc'dure.  The  ureters  were 
located  in  this  maimer  in  Cases  3113  and  3.")!)(). 

*J.  Sampson,  .Inliiis  Hopkins  llosp.  liriU.,  I'.tOl,  xv.  p.  .10. 
25 


CHAPTKR  XXII. 

THE  RECTAL   FINDINGS  IN  CASES  OF  UTERINE  MYOMATA. 

Adhesions  hctwccii  the  utci'us  and  rectum. 
Upward  di.<ii)la('eni('nt  of  the  rectum. 
Injury  to  the  rectum  durinii;  o|)eration. 
Resection  of  a  portion  of  the  sigmoid. 
Perforation  of  the  rectum  found  at  autopsy. 
Passage  of  an  enema  into  the  abdominal  cavity. 
Rectal  prolapsus^ 
Perirectal  abscess. 
Carcinoma  of  the  sigmoid. 


Adhesions  Between  the  Myomatous  Uterus  and  the  Rectum. 
In  a  moderate  number*  of  the  cases  slight  or  dense  adhesions  are  found  between 


the  tumor  and  the  rectum. 


Fig.  269. — Densk  Adhesions  Between  the 
Sigmoid  \sd  a  Myomatous  UTERts. 
Gyn.  No.  1499.  The  sigmoid  is  lifteil 
up  and  densely  adherent  to  the  posterior 
surface  of  the  uterus.  The  appendix  is  also 
firmly  glued  to  the  posterior  surface  of  the 
tumor. 


riiese  adhesions  may  occur  when  the  appendages 
are  normal,  Init  are  usually  associated  with 
general  pelvic  adhesions  and  are  particularly 
jn'oiie  to  occur  when  a  pelvic  abscess  exists. 
The  rectal  adhesions  may  be  low  down  near 
the  cervix  or  may  l)e  limited  to  the  sigmoid 
flexure.  Fig.  269  is  a  good  example  of  a  sig- 
moid densely  adherent  to  the  posterior  sur- 
face of  the  myomatous  uterus  Fig.  270 
shows  dense  adhesions  of  the  sigmoid  and 
also  of  the  small  l)owel  to  a  tubo-ovarian 
abscess  complicating  a  myomatous  uterus. 
For  adventitious  vessels  passing  from  the 
rectum  to  the  myomatous  uterus  .see  p.  42. 


Upward  Displacement  of  the  Rectum  by  Uterine  Myomata. 
If  the  myoma  pushes  out  beneath  the  me.so.sigmoid,  with  the  continued  growth 
of  the  tumor  the  sigmoid  will  be  carried  up  on  the  surface  of  the  myoma.  This 
was  the  ca.se  in  (lyn.  No.  1499  (Fig.  2(39j.  In  Case  4S2S  the  redundant  portion 
of  the  sigmoid  was  carried  uj)ward  beyond  the  umbilicus.  In  some  cases  it  seems 
as  if  the  jjelvic  structure  were  di-agged  upward  en  ///a.s.se  by  the  myomatous  uterus. 

♦Rectal  ndhesions  were  noted  in  Gyn.  Nos.  2207,  2638,  2706,  2800,  3107,  33.37,  So.Vi.  3661. 
3844.  4097,  4334.  4370,  5014.  5325.  6607.  6863.  7266.  7511,  7.")97,  8115,  9118,  9694,  9769,  10749A, 
11647,  12520,  12779,  12841,  C.  H.  I.  382. 

386 


THE    RECTAL    FINDINGS    IN    CASES    OF    UTERINE    .MYOMATA. 


38^ 


For  example,  in  Case  4097  l)oth  the  bladder  and  rectum  were  carried  high  into 
the  abdomen.  In  Case  1682  the  bladder  reached  15  cm.  above  the  symphysis, 
while  the  sigmoid  flexure  had  been  carried  out  of  the  pelvis  and  lay  over  the 
surface  of  the  tumor.  In  Case  3133  the  condition  was  even  more  pronounced. 
Xot  only  had  the  bladder  and  the  rectum  been  carried  upward,  but  oik;  ureter 
was  adherent  to  the  posterior  surface  of  the  tumor. 


Injury  to  the  Rectum  During  Operation. 

Injury  to  the  rectum  during  operation  has  occurred  in  several  cases.  In  all  of 
them  the  myomatous  uterus 
has  been  firmly  adherent  to 
the  rectum,  and  during  the 
liberation  the  bowel  has  been 
torn. 

The  rectal  tears  are  natur- 
ally divisible  into  two  groujjs: 

1.  Tears  involving  the 
muscular  coats  only. 

2.  Tears  extending  into 
the  lumen  of  the  rectum. 

Tears  Implicating  the  Cir- 
cular Coats. — Tears  of  the 
longitudinal  and  in  some  in- 
stances also  of  the  circular 
coats  were  noted  in  Cases 
2706,  4097,  4370,  5325,  6607, 
SI  15,  and  12841.  Some  were 
very  slight  in  extcMit,  others 
5  cm.  long  and  4  cm.  broad. 

Tears  into  the  Rectal 
Lumen.  —  In  (i\c  cases  the 
lumen  of  the  bowel  was  e\- 
|)ose(l  (liiriiit!;  relii()\-al  of  the 
tumor — four  times  accident- 
ally, and  once  when  it  was  deenn'd   neeessai'v  to  i-eino\e   a    piece  of   the  bowel. 

In  Case  9694,  after  bisection  and  i'emo\al  of  the  densely  adherent  myomatous 
uterus,  a  hole  1.5  cm.  in  dianietei'  was  torn  in  the  rectum  dui-iim  the  libeiation  of 
adherent  right  ap|)endages. 

In  Case  12520  the  myomatous  utei'us  was  en\'elo])ed  in  dense  jiehic  ad- 
hesions and  there  was  a  |)elvic  abscess.  In  libei-ating  tlie  inllamed  left  append- 
ages a  teai\  two  inches  long,  was  made  in  the  rectinn. 

The  injury  to  the  bowel  in  Case  501  I  was  veiy  extensive  ( l''ig.  271  ).      During 


I'lG.  270. — Dknmk  .\i)Hksions  of  thk  Sicmoik  Fi.kxi  rk  and  ok  a 
Loop  ok  Small  Howkl  to  a  Tubo-ovariax  .\b8ck8.s. 
(lyi).  No.  4.370.  The  uterus  contains  several  myomatous  nod- 
ules. On  the  left  is  a  large  tubo-ovarian  abscess,  to  the  upper  por- 
tion of  which  the  sigmoiil  and  a  loop  of  small  bowel  are  a<lherent. 
I'he  chief  difficulty  in  these  cases  consists,  however,  in  libeniting  the 
lower  part  of  the  rectum  from  the  abscess  wall. 


388 


.MYOMATA    OF   THK    T'TKRUS. 


removal  of  the  iiiiivcisally  adherent  iiiyoinatous  uterus  the  l)Owel  wa.s  torn  for  two- 
thirds  of  its  circuinferenee.  The  (ipeiiiiiii;  was  at  once  chjsed  with  fine  silk  sutures. 
The  operation  in  Case  12779  was  exeeedin<i-ly  ditheult  as  a  result  of  the  ad- 
hesions. On  the  left  side  was  a  tubo-ovarian  abscess,  the  lining  of  which  closely 
resembled  bowel  mucosa.  Dui-ing  libei'atioii  of  the  ri^ht  appendages  the  rectum 
was  opened  for  H  inches.  It  was  impossible  to  free  the  rectum  from  the  cervix, 
owing  to  the  dense  adhesions.  A  flap  of  the  cervix,  attached  to  which  was  a  torn 
piece  of  the  bowel,  was  dissected  free  and  turned  back  on  the  bowel  to  close  the 
rectal  deficiency. 

At  ojM'i'ation  in  Case  11047  the  ])elvic  growth  was  thought  to  be  carcinoma- 
tous. Complete  hysterectomy  was  per- 
formed and,  as  the  rectum  was  densely 
adherent  to  the  cervix  and  the  tissue 
much  indurated,  an  elliptic  piece  of  the 
rc^ctum  was  removed  with  the  uterus, 
and  the  opening  closed  with  a  row  of  silk 
sutures  first,  and  then  with  a  row  of  cat- 
gut sutures. 

Whenever  feasible,  it  is  well  to  get  at 
the  rectal  adhesions  from  the  under  side. 
This  may  be  accomplished  by  bisecting 
the  uterus  (Fig.  357,  p.  610),  or  by  first 
dissecting  back  the  bladder  and  amputat- 
ing through  the  cervix  (Fig.  363,  p.  616), 
before  tying  off  the  broad  ligaments.  In 
this  way  the  partially  ol^literated  Doug- 
las' sac  is  at  once  exposed.  When  it  is 
necessary  to  liberate  the  rectum  and  it  is 
impossil)le  to  dissect  it  free,  a  thin  shell  of 
the  tumor  should  be  left  attached  to  the 
rectum.  This  raw  area  is  then  turned  in  on  itself  and  sutured,  leaving  a  per- 
fectly smooth  surface.  This  procedure  was  successfully  carried  out  in  Case  6607. 
Where  only  the  outer  coats  of  the  l)owel  ar(>  torn,  one  or  more  continuous  cat- 
gut sutures  are  all  that  are  necessary  to  bring  the  raw  surfaces  together.  But 
if  the  lumen  of  the  bowel  is  entered,  the  opening  should  be  closed  with  fine  silk  or 
Pagenstecher  sutures,  and  then  reinforced  with  a  second  continuous  suture  of 
catgut.  A  vaginal  drain  should  then  be  introduced  for  safety.  It  should  be 
very  small,  and  so  placed  that  it  does  not  lie  on  the  sutiu'e  line,  as  it  may  h^ad  to 
suppuration  and  the  development  of  a  fecal  fistula. 

Under  no  circumstances  should  rectal  enemata  be  oi-dered  where  an  incom- 
plete or  coni))lete  rectal  tear  exists. 

In  all  of  these  cases  the  rectal  wounds  healed  pei'fectly,  and  the  ])atients 
made  a  good  recovery. 


Fig.  271  .^An  Extensive  Rectal  Tear. 

Gyn.  No.  5014.  During  the  removal  of  a  very 
adherent  myomatous  uterus  the  bowel  was  torn 
for  two-thirds  of  its  circumference.  The  opening 
in  the  rectum  was  sutured,  and  the  cervix  carefully 
covered  over  with  peritoneum  The  patient  re- 
covered satisfactorily. 


THE    KKCTAL    FINDINGS    IN    CASES    OF    UTERINE    MYOMATA. 


389 


Resection  of  a  Portion  of  the  Sigmoid  and  Removal  of  a  Myomatous  Uterus. 
The  nuiltinodular  iiiyoniatous  uterus  (Fig.  272)  was  of  moderate  size.     On  the 
right  side  was  an  ovarian  cyst;   on  the  left,  a  tuho-ovarian  abscess,  adherent  to 


Tubo-  ova  rian 
abscess 


Fig.  272. — A  Multixodulak  Myomatous  Uterus,  Complicated  by  an  Ovarian  Cyst  on  the  Right  and  a 
Densely  Adherent  Tubo-ovarian  Abscess  on  the  Left. 

Gyn.  No.  8738.  Path.  No.  49.35.  The  uterus  contains  several  myomatous  nodules;  it  measures  8  x  10  x  12 
cm.  The  cyst  on  the  right  was  16  cm.  in  diameter,  and  had  a  twisted  pedicle.  It  was  multilocular  and  had 
papillary  masses  springing  into  its  cavity. 

On  the  left  side  is  a  t\ibo-ovarian  abscess,  densely  adherent  to  the  small  bowel,  and  jilastered  down  to  the 
rectum.     For  the  intimate  relation  between  this  inflammatory  mass  and  the  sigmoid  see  Fig.  273. 


Tub 


Fk;.  273. — .\  Tiito-dVMd  \N  ,\hm 


/Sigmoid 


IV  AimiKKNT  to  thi:  Sii;m()II(   I'i.kxirk. 


Gyn.  No.  8738.     Path.  No.  4!K{.'i.      For  the  Reneral   relations  of  the  absees.s  see  Fig. 


The  absccis  sac 


has  been  cut  in  two.  To  the  left  is  a  cros.'s-section  of  the  greatly  thickened  tube.  The  two  large  irregular 
cavities  are  loculi  of  the  ab.scess  and  are  lined  with  granulation  tissue.  a  is  a  snudi  abscess  surrounded  by 
dense  new  connective  tissue.  The  bowel  at  this  point  is  .so  intinuitely  blended  with  the  abscess-wall  that  it 
would   bo   absiiliitel.N-    iiii|>o»iblr   In  di>sccl    il   ofT. 


tlie  small  howcl  and  sigmoid  (lexiirc     So  dense  were  I  he  adhesions  of  the 


moid 


390  MVO.MATA    OF    THE    UTERUS. 

(Fig.  273)  that  a  n'scction  of  a  ixiition  was  necessary.     The  recovery  was  nat- 
urally slow. 

Gyn.  No.  8738.     Path.  No.  4935. 

A.  H.,  single,  aged  thirty-seven,  white.  Admitted  May  10;  discharged 
August  6,  1901. 

Three  years  ago  the  patient  had  an  attack  of  abdominal  pain,  which  was 
supposed  to  be  (hie  to  api)endicitis.  Six  months  later  she  had  a  similar  attack, 
accompanied  l)y  an  inability  to  void.  About  this  time  a  small  tumor  was  noted 
in  the  left  side. 

Operation,  May  11,  1901.  Hysteromyomectomy;  resection  of  a  portion  of  the 
sigmoid  flexure.  The  uterus  was  synunetrically  enlai'ged.  This,  together  with 
the  ovarian  cyst  on  the  left  side,  was  removed.  In  order  to  enucleate  the  tubo- 
ovarian  mass  on  the  left  side  it  was  necessary  to  resect  about  12  cm.  of  the  sig- 
moid flexure.  A  gauze  drain  was  carried  down  through  the  inguinal  incision  to 
the  ]K)int  of  resection.  The  j)atient  was  much  shocked.  After  the  operation  the 
patient  hiccoughed  a  good  deal  and  had  much  nausea  and  abdominal  pain.  It 
was  impossible  to  move  the  bowels.  On  the  sixth  day  an  inguinal  colostomy 
was  done  in  order  to  relieve  the  obstruction.  The  patient  improved  rapidly. 
Several  days  later  an  attempt  was  made  to  close  the  fistulous  opening  under 
cocain.  but  the  stitches  tore  out.     The  patient  made  a  slow  recovery. 

Perforation  of  the  Rectum  Found  at  Autopsy,  Nine  Days  After  Hysterectomy 

FOR  A  Densely  Adherent  Myomatous  Uterus,  Associated  with 

Pyosalpinx  and  an  Ovarian  Abscess. 

The  accomi)anying  history  does  not  render  it  clear  whether  the  rectal  per- 
foration was  a  result  of  the  operation  or  merely  a  ])art  of  the  ulcerative  process 
found  in  other  portions  of  the  bowel.  Had  it  been  due  to  the  operation,  the  acute 
manifestations  would  in  all  probabihty  have  developed  earher. 

Gyn.  No.  5302.     Aut.  No.  954. 

E.  H.,  single,  aged  forty-six,  colored.  Admitted  May  29;  died  June  19, 
1897. 

The  lower  two-thirds  of  the  abdomen  was  filled  with  a  solid  tumor,  irregular  in 
outline.  Hysteromyomectomy  was  performed.  The  appendix  was  involved 
in  an  abscess.  Th(>re  were  dense  adhesions  to  the  pelvic  floor,  rectum,  colon,  and 
anterior  abdominal  wall.     The  operation  was  a  very  diflicult  one. 

After  operation  the  urine  showed  many  casts — an  exacerbation  of  an  old 
nephritis.  Saline  infusions  were  given  twice  daily.  There  were  nausea  and 
vomiting,  the  feces  began  to  pass  involuntarily,  and  the  patient  died  in  a  coma- 
tose condition  on  the  ninth  day.  Her  highest  postoperative  temperature  was 
102°  F.  on  the  day  of  her  death. 

Aut.  No.  954.  On  section  of  the  abdomen  perforation  of  the  sigmoid  flexure 
was  found.     There  were  a  localized   purulent   ])eritonitis  and  an  acute  general 


THE    RECTAL    FINDINGS    IX    ("ASES    OF    UTERINE    MYOMATA,  391 

peritonitis,  arteriosclerosis,  chronic  diffuse  nephritis,  chronic  adhesive  pleuritis, 
and  ulceration  of  the  large  intestine. 

The  Passage  of  an  Enema  into  the  Abdominal  Cavity. 
In  Case  10749J,  described  in  detail  on  p.  675,  the  patient  suddenly  collapsed 
on  the  third  day  after  a  simple  enema  had  been  given.     At  autopsy  on  the  follow- 
ing day  it  was  found  that  there  was  a  hole  3  cm.  long  in  the  rectum,  and  through 
this  the  enema  had  passed  into  the  general  cavity,  at  once  setting  uj)  a  peritonitis. 

Rectal  Prolapsus. 

This  would  naturally  seem  to  be  a  frequent  accompaniment  of  uterine  myo- 
mata,  but  it  was  noted  only  twice  in  our  series. 

In  Case  5987,  in  which  the  uterus  had  been  converted  into  a  nodular  tumor, 
11  X  12  X  17  cm.,  a  small  mass  had  protruded  from  the  anus  for  a  year. 

In  Case  5249  the  patient  had  consulted  her  physician  five  years  before  opera- 
tion, on  account  of  prolapsus  of  the  rectum,  and  was  then  told  that  she  had  a 
uterine  tumor. 

Perirectal  Abscesses. 

Pelvic  abscesses  are  not  infrequently  associated  with  uterine  myomata,  and 
the  rectum  under  such  conditions  is  often  implicated  in  the  general  process.  The 
two  following  cases  are,  however,  very  unusual. 

In  Case  5697,  after  removal  of  a  small,  densely  adherent  myomatous  uterus, 
which  was  associated  with  chronic  salpingitis  on  both  sides,  and  with  a  small 
pelvic  abscess,  another  abscess  was  accidentally  discovered  behind  the  rectum, 
just  as  the  abdomen  was  about  to  be  closed.  This  sac  was  wiped  out  and  drained 
through  the  vagina.  Had  this  abscess  not  lieen  (Hscovered,  recovery  might  have 
been  greatly  retarded. 

In  Case  6199  a  small  myomatous  uterus  was  associated  with  peh'ic  inllamiua- 
tion.  The  infection  had  exteii(h'd  to  the  rectovaginal  septum,  which  was  fully 
3  cm.  in  thickness. 

In  Case  8264,  shoi'tly  after  abdominal  uiyoiiicctomy.  the  patient  underwent 
three  successive  oj)eratioiis  for  ischiorectal  abscess.  The  i-ectal  conditioii  in  this 
case  must  be  considered  merely  as  a  coinci(UMice. 

Carcinoma  of  the  Sigmoid  Flexure  Associated  with  Uterine  Myomata. 

(  )ii  p.  117,  in  the  autopsy  chapl  (T,  arc  d('scril)c(l  tw(»  cases  of  cancer  ol  the 
lowci"  bowel  associated  with  ulci'inc  myomata.  in  the  liisl  the  carcinoma  was 
situaied  in  the  signioiil  (lexure;  in  the  second,  within  1  cm.  of  the  anal  oi'ifice. 
in   iieithei'  case  was  operation   feasible. 

In  the  following  case  the  patient  entered  with  signs  of  obst  I'uction.  After 
a  lar<r<'  invomatous  utei'us  had  been  renio\'e(l,  ;i  carciiioina  of   the  si<j:moid  (lexure 


392  MYOMATA    OF    THK    UTERUS. 

was  discovered  (Fig.  274).  This  was  at  once  excised,  and  the  patient  enjoyed 
fair  health  for  several  weeks.  On  her  return  to  the  hospital  wide-spread 
abdominal  metastases  were  found. 

Gyn.  No.   12000.     Path.  No.  8447. 

Acute  intestinal  obstruction;  a  large  myomatous 
uterus  wedged  in  the  j)  e  1  v  i  s ;  unsuspected  a  d  e  n  o  c  a  r  - 
c  i  n  o  m  a  o  f  t  h  e  s  i  g  m  o  i  d  flexure.  Hysterectomy;  re- 
section   of  the  diseased  1)  o  w  e  1 ;  t  e  m  ])  o  r  a  r  y  r  e  c  o  v  e  r  y.* 

E.  S.,  colored,  aged  forty.  Admitted  .March  26;  discharged  June  9,  1905. 
One  of  us  (C.)  saw  this  patient  in  consultation  with  Dr.  Clement  A.  Penrose. 
On  admission  she  was  suffering  from  intestinal  o])st ruction.  This  was  thought  to 
be  caused  by  a  myoma  which  had  Ix'en  known  to  exist  for  hfteen  years.  Twelve 
years  before  she  had  had  a  severe  attack  of  abdominal  pain.  This  was  sharp 
and  shooting  in  character,  but  there  was  no  intestinal  ol)struction.  For  the  past 
six  weeks  she  had  noticed  sharp  shooting  pains  in  the  al)domen,  intermittent  in 
character,  and  limited  to  the  left  side.  The  bowels  had  not  moved  for  several 
days.     There  had  been  no  blood  noted  in  the  stools  prior  to  the  obstruction. 

The  abdomen  was  at  once  opened.  After  removal  of  the  myomatous  uterus 
(Fig.  274)  the  rectum  was  found  to  contain  what  appeared  to  be  a  malignant 
growtli.  The  rectal  tumor  was  loosened  as  carefully  as  possible  from  the  cervix. 
It  lay  entirely  below  the  ])elvic  brim,  was  approximately  7  cm.  in  diameter,  and 
about  8  cm.  in  length.  The  tumor  was  removed,  and  an  end-to-end  anastomosis 
done.  In  order  to  give  the  anastomosis  complete  rest,  a  left  inguinal  colostomy 
was  done.  The  patient  was  very  weak  when  r(>turned  to  the  ward,  but  in  fairly 
good  condition,  considering  the  severity  (;f  the  operation.  She  gradually  im- 
proved, and  was  discharged  on  June  9th. 

Path.  No.  8447.  The  myomatous  uterus  has  l^een  amputated  through  the 
cervix.     It  is  approximately  11  x  12  x  16  cm.  (Fig.  274). 

Our  chief  interest  is  centere(l  in  the  growth  of  the  sigmoid  flexure.  The  piece 
of  tissue  is  9  cm.  in  length.  The  outer  covering  of  the  bowel  looks  fairly  normal, 
except  for  some  slight  whitish  elevations.  Occupying  the  entire  thickness  of 
the  bowel  near  the  center  is  a  hard,  light-colored  growth  (Fig.  274,  c).  This  is 4 
cm.  in  length,  and  extends  throughout  the  entire  thickness  of  the  bowel.  The 
growth  itself,  with  the  induratetj  adipose  tissue  sun'ounding  it,  is  fully  ;■)  cm.  in 
thickness. 

Histologic  examination  shows  that  the  tumor  of  the  bowel  is  a  typical  adeno- 
carcinoma. 

Gyn.  No.  12204.  The  patient  was  r(>admitted  on  June  24, 1905.  Until  a  Aveek 
previous  she  had  be(>n  in  good  condition.  The  bowels,  however,  became  con- 
stipated: there  were  fre<|ueiit  attacks  of  pain  in  1  he  abdomen,  and  during  the  last 

*Thi.s  ca.se  is  reported  in  detail  in  "  .\  Scries  of  Intestinal  Anastomoses,"  Thoinas  S.  Ciillen, 
Canadian  Jour,  of  Med.  and  .Siui;.,  .July,  190(). 


THE    KKCTAL    FINDINGS    IX    CASES    OF    UTERIXE    MYO.MATA. 


393 


seven  days  there  had  hcen  no  niovement.  For  the  last  two  or  three  days  the 
abdoniinal  |)ain  had  inci'cascd  in  severity,  but  tlicrc  had  been  no  vomiting. 
The  patient  gradiudly  grew  weaker,  and  died  .July  3,  IIH)."). 

Aut.  No.  2558.     The  autopsy  revealed  a  recurrenee  of  the  careinonia  at  the 


Fig.  274. — Cakcinoma  ok  the  Siumoio  Flexurk  -Associatki)  with  a  Myomatous  Uthrvs. 

Gyn.  No.  12000.  Path.  No.  8447.  After  sketching  a  longitudinal  section  of  the  pelvis,  the  artist  ilrew  the 
uterus  and  growth  in  the  bowel  from  nature.  The  uterus  measures  11  .x  12  x  16  cm.,  and  almost  completely  fills 
the  pelvis,  leaving  little  room  for  the  hhwkler  or  rectum.  It  contains  numerous  interstitial  and  a  few  submucous 
myomata.  The  uterine  cavity  is  slit-like,  hut  at  a  is  slinlillx-  dilatril.  Tlic  linht  palches.  h,  in  the  myoma  art- 
areas  of  calcification. 

Occupying  the  sigmoid  is  the  carcinomatous  growth,  c,  whicli  ahucsi  (•iiinpl<'ii'l,\  lilN  the  limuMi  of  ihc  bowel. 
Its  confines  are  indicated  by  d  and  d'.     (After  Thomas  S.  ('ullcn.  i 


point  of  anastomosis.  Tiici'c  \\'as  also  some  ii;in'o\\  iim  ol'  ilic  bowel  ;ii  this 
point.  There  were  mct.-istasrs  in  llic  iicritoiiciiiii  ;iiid  :\  liliiiiio|iurulciii  peri- 
tonitis, apparently  nrisinti  in  the  u|)|)<'i-  riiiiil  MlMloniiiiMl  (|ii;idr:int ,  :it  a  [joint 
far  removed  from  the  site  of  the  ;iii;isloniosis. 


CHAPTER  XXIII. 

ANALYSIS  OF  THE  CASES  OF  UTERINE  MYOMATA  FOUND  AT  AUTOPSY 
IN  THE  PATHOLOGICAL  LABORATORY  OF  THE  JOHNS  HOPKINS 
HOSPITAL  FROM  THE  OPENING  OF  THE  HOSPITAL,  IN  1889,  TO 
JULY  I,  1906. 

Through  the  kindness  of  Professor  W'ilhani  H.  Weh'h  the  autopsy  records 
of  the  Johns  Hopkins  Hospital  have  been  {)hiced  at  our  disposal  From  the  open- 
ing of  th(>  hospital,  in  1889,  to  July  1,  1006,  there  have  been  2740  autopsies. 
In  2729  cases  complete  data  are  availal)le.  The  accompanying  tabulation  gives 
the  relative  number  of  males  and  females,  and  also  the  ratio  of  white  and  blacks: 

Males,  white 1102 

Males,  black 659 

Females,  white 537 

Females,  black 431 

It  will  be  seen  that  the  number  of  males  nearly  doubles  that  of  females,  and 
that  the  ratio  of  l)lack  to  white  women  is  1  to  1.25. 

As  myomata  are  rarely  present  in  women  under  twenty  years  of  age,  we  have 
only  inclutled  autopsies  upon  women  of  twenty  or  over.  Of  these,  there  were  in 
all:' 

( )n  white  female.s  of  twenty  years  of  age  or  over 431 

On  black  females  of  twenty  years  of  age  or  over 311 

Total 742 

In  14S  of  these  cases  the  uterus  contained  one  or  more  myomata;  in  other 
words,  in  about  20  per  cent,  of  the  autopsies  in  women  of  twenty  years  of  age 
or  over  the  uterus  was  the  seat  of  a  myomatous  growth.  This  is  certainly  a 
remarkable  showing. 

The  following  table  gives  the  number  of  eases  according  to  decades: 

In  patients  between  20  and  ;•>()  years  of  age  myomata  were  found  in  14  cases. 

.■•iO    ••    40        "      •'      •'  ' 38     " 

"        "  "         40    "    .50       "     "     "  "  "         "       "  52     " 

.iO  "  (iO  "  "  "  "  "  "  "  29     " 

(SO  ■'  70  "  "  "  "  "  "  "  10     " 

70  "  80  "  "  "  "  "  "  "  4     " 

"         80  "  90  "  "  "  "  "  "  "     1  case. 

Of  the  14.S  patients,  4'A  were  white  and  lOo  black.  In  other  words,  33.7 
per  cent,  of  all  the  black  women  twenty  years  of  age  or  over  coming  to  autopsy 
had  uterine  myomata,  wliile  only  10  ])er  cent,  of  the  white  ])atients  were 
affected  in  this  way. 

394 


AUTOPSY    FINDINGS, 


395 


Themyoniata  varictl  from  0.5  to  27  x  17  x  13  cm.  in  diameter,  the  largest 
being  found  at  autopsy  No.  1969.  In  some  of  the  cases  only  one  myoma  was 
present.  Usually  the  uterus  contained  several  nodules,  and  in  one  case  fifteen 
were  noted. 

Fig.  275  shows  a  small  myomatous  uterus  removed  at  auto])sy  from  a 
patient  ninety  years  of  age. 

Site  of  the  Tumors. — In  30.4  per  cent,  only  subperitoneal  nodules  were  found. 

In  2().3  per  cent,  only  interstitial  nodules  were  noted. 

In  15  per  cent,  subperitoneal  and  interstitial  nodules  were  found. 

In  only  a  few  were  submucous  nodules  detected.  Subperitoneal  or  inter- 
stitial myomata,  when  not 
large  enough  to  occasion  any 
pressure  symptoms,  in  the 
majority  of  cases  cause  little 
trouble  and  consequently  the 
patient  rarely  comes  to  the 
surgeon  for  treatment. 

Adhesions. — In  48.6  per 
cent,  old  pelvic  adhesions 
were  found. 

In  7.6  per  cent,  pelvic 
and  abdominal  adhesions 
were  noted. 

In  all,  56.2  per  cent,  of 
the  cases  were  complicatetl 
by  adhesions  of  some  char- 
acter. 

Degeneration. — In  12.2  per  cent,  portions  of  the  myomata  were  necrotic* 

In  15.5  per  cent,  calcareous  deposits  were  present. f 

Of  course,  in  these  cases  showing  calcareous  (.lei)osits  areas  of  necrosis  had 
preceded  ihe  deposition  of  the  calciiun  salts,  so  that  at  one  time  or  another 
in  25  per  cent,  of  the  cases  necrosis  was  present  in  one  or  more  of  the  myomata. 

Cystic  or  hyaline  changes  were  detected  in  8  cases  (about  5.5  per  cent.) — 
Nos.  288,  54,  85,  188,  1113,  1206,  1969,  2080. 


Fig.  275. — Myomata  in  Old  Age.  (|  nat.  size.) 
M.  S.  Aut.  No.  1823.  Path.  No.  5471.  This  uterus  was  re- 
moved from  a  patient  ninety  years  of  age,  dead  of  an  intercurrent 
affection.  The  organ  is  enlarged  only  slightly.  Occupying  the 
fundus  are  a  few  small  interstitial  nodules;  projecting  from  the  fun- 
dus are  three  small,  irregular,  nodular  myomata,  all  of  which  appear 
to  have  undergone  some  atrophy. 


Condition  of  the  Tubes  and  Ovaries  noted  in  Myoma  Cases  at  Autopsy. 

In  5().2  per  cent,  of  all  the  myctma  cases  pelvic  or  abdominal  adhesions  were 
found.  Naturally,  tlieii,  we  should  expect  to  liiul  numerous  minor  i)athologic 
lesions  in  the  tubes  ami  o\'aries. 


*  .\ut.  .\()K.  (19,  \:u],  iss,  277.  ;rJL',  474,  .");v_'.  mo.  (;.■>:•;,  (iso,  (is't.  7(io.  7i.'l'.  los.",.  i7.")4.  -Joso,  2()sr, 

2202. 

t  .\ut.  Xos.  2:i.  (>(t.  1  17,  .')!<).  .")7i»,  (iS2,  700,  722.  (101.  OOS.   \:\H).  ]:VA7 .  I'.UV.';.  l.")!);<.  KiOd    17(,o, 
lS2;i   l,S(i!»,   1S9S,  20SS,  22;<0,  2  10  1.  2r2(). 


396  .MVo.MATA    OF    TIIK    ITKUrS. 

Hydrosalpinx,  unilateral ^  oases 

Hydrosalpinx,  liilatcral 5 

Hematosalpinx 1  case 

Pyosalpinx 4  cases 

Tuberculosis  of  the  tu!)e  (Aut.  No.  1898) 1  case 

Carcinoma  of  tlic  Fallopian  tuhc  (Aut.  No.  810),  .secondary  to  carcinoma  of 

the  uterus, 1 

Small  cyst  "in  the  broad  ligament " 6  cases 

Multilocular  cystadenoma  of  l)oth  ovaries 1  case 

Dermoid  cyst 2  cases 

Ovarian  abscess 4 

Tubo-ovarian  abscess 1  case 

Primary  carcinoma  of  the  ovary  (Aut.  Nos.  474  and  \'M\) 2  cases 

Carcinoma  of  the  ovary  associated  with  carcinoma  of  the  stomach* 2       " 

The  snuill  cysts  noted  in  tlie  brojul  ligament  are  cliiefi}^  intlannnatory  in 
origin,  l)eing  due  to  accumulations  of  peritoneal  fluid. 

From  a  study  of  this  table  it  will  be  seen  that  in  two  of  the  cases  there  were 
])rimary  malignant  changes  in  the  ovaries,  and  in  one  case  tuberculosis  of  the 
Fallopian  tub(\ 

Changes  in  the  Ureter  Associated  with  Myomata.! 
The  following  table  shows  that  in  these  cases  one  or  both  ureters  were  dilated, 
o'ivin";  rise  to  lix'di'oui'eter: 


Right  or  Left 

Aut.  No 

SlZK  OF    UtKUUS. 

Adherent. 

Hydroureter. 

Cause. 

288 

Large,  filling  pelvis. 

Yes. 

Double. 

Myoma. 

451 

3  myomata,  5  cm.  in 
diameter. 

Right. 

Was  associated 
with  diffuse 
nephritis  and 
cardiac  hy- 
pertrophy. 

Myoma. 

653 

Pelvis  filled. 

Yes. 

Double. 

Myoma. 

908 

9x7  cm. 

— 

Double. 

Myoma 
(jammed), 

994 

Ri.ses  i:!  cm.  above 

liight. 

Myoma. 

pelvic  hriiii.  — 

The  situation  and  the  size  of  the  tumor  are  to  a  great  extent  responsible  for 
pressure  upon  the  ureter  sufficient  to  caus(>  dilatation.  A  myoma  just  large 
enough  to  fill  the  pelvis  and  snugly  tied  down  by  adhesions  can  very  readily 
produce  sufhcient  j)ressun'  to  cause  hydrourelci-,  while  a  very  hirge  tumor  may 
be  so  .situated  as  to  exert  liltle  or  no  effect  upon  the  ureter. 

In  the  removal  of  an  S<.)-])()und  tumor  in  the  week  during  which  we  were 
gathering  this  data  we  did  not  find  the  slightest  cNidcnce  of  any  interference  with 

*The  intimate  relat  ion>liip  between  ])riinary  carcinoma  of  the  stomach  and  secondary  growths 
in  the  ovaries  was  made  clear  by  Professor  Welch  several  years  ago  (Pepper's  System  of  Med., 
vol.  ii,  p.  533). 

fin  several  other  cases  ureteral  and  renal  changes  were  fount!,  but  as  they  were  evidently 
caused  by  other  pathologic  conditions,  these  cases  have  been  omitted. 


AUTOPSY    FINDINGS.  397 

the  ureter.  About  the  only  way  in  which  llie  myoma  can  ])riiig  about  the  nec- 
essary pressure  on  the  ureter  is  to  get  it  hrmly  wedged  against  the  ])ony  wah 
of  the  pelvis.  As  a  rule,  the  larger  the  myoma  becomes,  the  more  room  it  requires, 
and  hence  its  ascent  into  the  general  cavity. 

In  Aut.  No.  451  the  combined  myomatous  masses  with  the  associated  adhesions 
seem  to  have  been  the  causative  factor. 

In  Aut.  Nos.  653,  908,  and  994  the  evidence  is  in  favor  of  the  myomata  as  the 
distinct  cause  of  the  hydroureter. 

There  was  one  more  case  in  which  hydroureter  was  found  at  autopsy  (No. 
188).  Here  the  ureter  had  been  accidentally  tied  during  operation,  and  had 
remained  so  until  several  days  later,  when  it  was  discovered  at  autopsy.  This 
case  is  described  in  full  on  p.  382. 

In  one  case  (Aut.  No.  69)  there  was  a  double  pyoureter  associated  with 
an  ascending  infection  and  implication  of  both  kidneys.  The  large  myomatous 
tumor  was  sufficient  to  cause  dilatation  of  the  ureters,  but  the  accompanying 
infection  could  not  be  directly  attributed  to  the  uterine  tumor. 

Changes  in  the  Kidney  Associated  with  Uterine  Myomata. 

Aut.  No.  288,  double  hydronephrosis. 

Aut.  No.    653,  double  hydronephrosis. 

Aut.  No.    994,  dilatation  of  the  right  pelvis. 

Aut.  No.  1745,  dilatation  of  the  right  pelvis. 

Aut.  No.      69,  double  pyelonephrosis. 

Aut.  No.  1112,  miliary  abscesses  of  the  kidney  (Staphylococcus  aureus, 
sloughing  submucous  myoma). 

In  Aut.  Nos.  288  and  994  the  dilatation  of  the  ureter  seemed  to  have  l)een 
caused  by  pressure  exerted  by  the  myomata,  which  was  likewise  ])i'()l)ably  re- 
sponsible for  the  dilatation  of  the  renal  pelves. 

In  Aut.  No.  1745  the  coexistence  of  the  myoma  witli  dilatation  of  the  right 
kidney  w'as  a  mere  coincidence. 

The  dilatation  of  the  kidney  in  Aut.  Xo.  69  was  ])i-ini;irily  due  to  ])ressure 
exerted  by  the  tumor,  but  the  .subsecpient  infection  cainiot  be  attiibiited  to  the 
presence  of  the  myomatous  uterus. 

The  general  picture  in  Aut.  No.  1112  strongly  suggests  that  the  sloughing 
submucous  myoma  was  responsible  for  the  acute  endocarditis,  with  the  secondaiy 
manifestations,  as  seen  in  the  miliary  ab.sce.sses  in  the  kidney. 

Taken  as  a  whole,  the  alterations  in  tluMUvters  and  kidneys  c;iused  by  myomata 
are  chiefly  lueclianical,  and  may  to  a  gi'cat  extent  be  i'elie\('d  by  o|ieralioii.  (  )iily 
in  those  cases  in  which  there  is  a  sloughing  sul»niucous  myoina  oi-  necrotic  and 
sloughing  interstitial  oi'  sul)i)eritoneal  myotnata  need  i)urulent  changes  be  looked 
for  in  the  ureter  or  the  kidney. 


398  MYOMATA    OF   THE    rTKRUS. 

Autopsies  Showing  Carcinoma  and  Myomata  in  the  Same  Uterus. 

In  8  cases  this  conditioii  was  found  at  aut()i)sy.  In  2  cases  the  carcinoma 
was  situated  in  tlie  cervix :  in  6  cases,  in  the  body  of  the  uterus. 

Carcinoma  of  the  Cervix  and  Uterine  Myomata.* — In  Aut.  No.  689  (Case 
3490)  the  cervix  had  been  inva(h'd  with  cancer,  which  had  extended  not  only  to 
the  lateral  structures.  l)ut  also  to  the  vag:ina.  Situated  in  the  l)ody  of  the  uterus 
was  a  sloughing  submucous  myoma,  6.5  x  4.5  x  2  cm. 

The  uterus  in  Aut.  No.  926  (Case  5092)  presented  a  striking  picture.  The 
cervix  had  lieen  entirely  eaten  away  by  the  carcinomatous  growth,  and  the  body 
of  the  uterus  was  markedly  encroached  uixni.  Scattered  throughout  the  uterus 
were  subperitoneal,  interstitial,  and  submucous  nodules,  and  the  carcinoma  had 
riddled  the  contiguous  ])ortion  of  the  myomata  (Fig.  278,  p.  403).  It  is  little 
wonder  that  the  large  carcinomatous  surface  gave  rise  to  a  fatal  hemorrhage. 

The  cases  operated  ui)on  in  which  carcinoma  of  the  cervix  was  associated  with 
myomata  will  be  found  on  p.  262. 

Gyn,  No.  3490.     Aut.  No.  689. 

Extensive  c  a  r  c  i  11  o  in  a  o  f  the  cervix;  sloughing 
s  u  b  m  u  c  o  u  s    m  y  o  m  a  . 

Aut.  No.  689.  K.  Pv..  white,  aged  forty-four.  .Vdniitted  May  7:  died  July 
18,  1895.  Anatomic  diagnosis:  general  infection  with  the  gas  bacillus;  carci- 
noma of  the  cervix  extending  to  the  vagina  and  lateral  structures;  metastases 
in  the  liver,  both  layers  of  peritoneum,  and  inguinal  and  retroperitoneal  lymph- 
glands;  arteriosclerosis;  chronic  diffuse  nephritis;  chronic  perisplenitis;  chronic 
adhesive  and  acute  peritonitis;  sloughing  myomata  in  the  uterine  cavity. 

On  opening  the  abdomen  900  c.c.  of  greenish,  foul-smelling  fluid  were  found 
free  in  the  peritoneal  cavity.  The  cervix  had  almost  entirely  disappeared, 
its  site  in  the  upper  part  of  the  vaginal  wall  being  infiltrated  by  the  carcinoma, 
which  laterally  extended  to  the  pelvic  wall.  The  growth  was  sloughing  and 
necrotic.  In  the  uterine  cavity  was  a  hard  nodule,  6.5  x  4.5  x  2  cm.,  which  showed 
a  necrotic  surface.  This  was  a  sloughing  subimicous  myoma.  Both  Fallopian 
tubes  were  thickened  and  adherent  to  the  posterior  surface  of  the  uterus. 

Histologic  examination  showed  that  the  growth  and  the  metastases  were 
com])osed  of  carcinomatous  tissue.  The  records,  however,  do  not  say  whether 
it  was  a  squamous-celled  growth  or  an  adenocarcinoma. 

Gyn.  No.  5092.     Aut.  No.  926.     Path.  No.    1631. 
Umbilical    hernia;    s  r  (  u  a  m  o  u  s  -  c  e  1  1  e  d    c  a  r  c  i  n  o  m  a    of 
the    c  e  r  v  i  X  (  F  i  g  .  2  7  6  )    extending    to    the    \'  a  g  i  n  a  ,    bod  y 

*In  Aut.  No.  810  (Ca.se  4;i74)  the  cervix  wa.s  extensively  invaded  by  the  carcinomatous  tissue, 
which  was  also  wide-spread  in  the  lateral  structures.  Two  small  interstitial  myomata  were  pres- 
ent in  the  body  of  the  uterus.  These  nodules  were  too  small,  however,  to  justify  the  inclusion  of 
this  case  in  the  group. 


AUTOPSY    FINDINGS. 


399 


of  the  II  t  e  r  us,  bladder  (Fig.  277),  r  e  c  t  u  in  ,  1)  r  o  a  d  liga- 
ment, t  u  1)  e  s  a  n  d  o  ^•  a  r  i  e  s  ,  a  n  d  f  o  v  m  i  n  g  ni  e  t  a  s  t  a  s  e  s  i  n 
the  pelvic,  inguinal,  retro  p  e  r  i  t  o  n  e  a  1  ,  ni  e  s  e  n  t  e  r  i  c  . 
and    bronchial    g  1  a  n  tl  s  ;     a  1  s  o    i  n    t  h  e    lung  s  ,    p  1  e  u  ra? ,    and 


Fk;.  276. — Squamous-cki.i.ed  CAnri.\OM.\  ui   iiii;  C'i:kvi.\.   .V.-smx  iai  i.d  with  Mri.Tipi.i-:  Utkrink  Myomata. 

(7  nat.  .size.) 
Path.  No.  1631.  The  uterus  i.s  much  enlarged.  Projecting  from  its  surface  are  numerous  large  anil  small 
bosses,  which  on  section  are  seen  to  consist  of  subperitoneal,  interstitial,  and  subnmcous  myomata.  Note  how- 
prominent  the  myomatous  nodules  are  on  section,  owing  to  the  rec«'ssion  of  the  uterine  muscle.  The  lower  part 
of  the  vagina  presents  the  normal  appearance.  l)ut  occupying  the  upper  part  of  the  vagina,  llie  site  of  tlie  cervix,  ami 
also  the  greater  part  of  the  uterus  is  a  ragged  and  friable  looking  growth,  composed  of  smootli,  dome-like  elevations, 
varying  from  a  pin's  head  to  2  cm.  in  diameter.  The  larger  ones  are  slightly  lobulated.  Over  the  smooth  inner 
surface  the  tissue  is  almost  entirely  necrotic.  The  uterine  walls  have  been  invaded  nearly  to  the  peritoneal  surface, 
and  present  a  very  ragged  outline.  The  small  nodules  in  the  nmscle  of  the  fundus  are  myomata.  The  growth  on 
microscopic  examination  is  found  to  have  jienetnited  the  muscle  between  them,  and  ha.s  invaded  a  snuill  myoma- 
tous nodule,  as  seen  in  Fig.  '27H.     (.\fter  11.  A.  Ki-ll\,  i 


the    s  e  r  o  s  a     o  I'     the     i  ii  t  c  s  t  i  n  c  s.      I  n  l  c  i-  s  i  i  i  i  ;i  1     ;i  n  d     s  u  b  - 

p  ('  r  i  t  ()  11  e  a  1     ii  1  c  r  i  n  c      iii  y  o  iii  ;i  t  ;i  ;     il  o  u  b  I  c  li  y  d  i'  i»  ii  i-  c  I  c  r  ; 

a  11  (■  III  i  a    of     all     I  li  c    o  r  g  ;i  ii  s  :     I'  o  c  ;i  I     I'  ;i  I  I  y  d  c  g  c  n  v  r  a  !  i  o  n 

o  1       the     1  i  \-  (•  r  :     i  n  t  c  r  s  1  i  t  i  a  I     n  c  |)  li  r  i  t  i  .s  ;  .s  u  d  tl  e  n     d  e  a  t  h 
foil  o  \v  i  n  ii    uteri  n  e    h  c  in  o  i'  r  h  a  ir  e  s  . 


4()0  MYOMATA    OF   THK    UTERUS. 

L.  S.,  aged  fifty-four,  colored.  Admitted  March  11,  1897.  Complaint, 
frequent  uterine  hemorrhages  and  an  offensive  discharge. 

The  patient  ha.s  been  married  twenty  years,  and  has  liad  two  children  and 
one  miscarriage.  Her  menses  commenced  at  thirteen,  were  regular  and  profuse, 
lasting  three  or  four  days,  and  very  painful.  Seven  years  ago  the  periods 
diminished  in  frequency,  occurring  once  in  every  three  or  four  months,  though 
there  was  frequently  a  bloody  discharge.  In  August,  1895,  the  bloody  discharge 
reappeared  and  became  constant,  but  not  excessive;  it  continued  until  January, 
1896.  Since  then  she  has  had  copious  hemorrhages,  and  after  one  in  January, 
1896,  she  fainted.  The  last  sev(n-e  hemorrhage  ])rior  to  her  admission  occurred 
in  September.  1896.  Since  then  at  times  she  has  had  a  bloody  discharge,  slight 
in  amount,  and  accompanied  by  no  pain,  but  very  offensive  and  irritating. 

On  admission  the  discharge  is  yellowish  white  and  profuse.  The  family 
history  is  negative. 

The  only  noteworthy  fact  in  her  ])revious  history  was  that  in  the  sunmier 
of  1896  she  had  no  stool  for  two  weeks. 

Pres(»nt  sickness:  The  ])atient  did  not  know  that  she  had  an  abdominal 
tumor  until  so  informed  by  her  ])hysician;  she  thinks  that  the  growth  has  dimin- 
ished in  size.  There  has  been  little  pain  in  the  abdomen,  except  for  the  ac- 
cumulation of  flatus.  Enlargement  of  the  inguinal  glands  was  first  noticed 
in  June,  1896.  These,  she  says,  have  not  increased  in  size,  but  during  the  last 
four  weeks  have  been  very  painful.  She  has  lost  much  in  weight,  although  she 
has  a  very  good  ap})etite.  The  l)owels  are  costive,  and  defecation  is  accompanied 
by  much  pain  and  occasionally  by  bleeding  from  hemorrhoids.  The  urine  is 
sometimes  scalding  and  occasionally  blood-tinged. 

Abdominal  Elxamination. — The  abdomen  is  dome-.shaped,  the  most  prominent 
point  being  the  umbilicus.  The  patient  has  an  umbilical  hernia,  the  pouch 
being  3  cm.  in  diameter,  and  ])rojecting  3.5  cm.  from  the  surface.  The  hernial 
ring  easily  admits  tlie  end  of  the  index-finger. 

The  abdominal  tenderness  is  most  marked  below  and  to  the  left  of  the  um- 
bilicus. Over  an  area  about  5  cm.  in  diameter  in  this  vicinity  the  tissue  is  very 
edematous,  and  pits  readily  on  pressure.  Owing  to  the  tenderness  it  is  diflficult 
to  outline  the  al)tlominal  tumor,  which,  however,  is  very  smooth  and  does  not 
extend  above  the  umbilicus  in  the  median  line.  In  both  inguinal  regions  the  glands 
are  as  large  as  walnuts  and  are  movable.     Those  on  the  right  side  are  tender. 

The  right  leg  is  much  swollen  and  pits  on  pressure,  especially  below  the  knee. 
The  left  leg  also  is  swollen.  The  glands  of  the  neck  and  the  epitrochlears  are 
palpable. 

Vaginal  Examination. — The  outlet  is  considerably  relaxed,  and  the  ui)per 
))art  of  the  vagina  is  occuj)ied  by  a  necrotic,  offensive  tissue  which  rapidly  breaks 
down  under  the  examining  finger. 

Further  examination  is  imjKJssible  on  account  of  the  extreme  tenderness. 

On  the  moi'ning  of  Mai'ch  27,  1906,  the  })atient   had  a  jn'ofuse  uterine  hemor- 


AUTOPSY    FINDINGS. 


401 


rhage,  and,  as  nearly  as  could  be  estimated,  lost  about  one  pint  of  blood.  So  far 
as  the  pulse  and  respiration  were  concerned,  the  loss  of  blood  caused  little  change, 
but  there  was  a  slight  tendency  to  drowsiness.  At  3.30  p.  m.  she  had  a  second 
hemorrhage,  more  profuse  than  the  first,  was  restless,  complained  of  severe  pain 
in  the  back,  and  had  a  pulse  of  136.  The  mucous  membranes  were  quite  pale. 
The  respirations  were  not  increased.  Morphin  was  given  with  good  effect. 
At  11.15  p.m.  she  had  a  third  hemorrhage,  much  more  severe  than  the  two 


.-i^°wuTa. 


^ydro  "  ilr^tej' 


Corn  n  o  - 


'Carri/T 

Caret  o  ■ 
nodule.!, 

L  c/'t  ur. 

ort'f/'cc 


'^'^t  ureteral   orcfi 

Fig.  277. — Carcinoma  of  the  Bladdkr  Secondary  to  Sijuamous-celled  Carcinoma  of  the  Cervix. 
Path.  No.  1631.  Scattered  over  the  peritoneal  surface  of  the  bladder  are  many  small  white,  flat,  isolated 
carcinomatous  nodules.  Some  also  have  united  to  form  conglomerate  masses.  The  bladder-walls  are  of  the  usual 
thickness.  Just  within  the  inner  urethral  orifice  is  an  elongated  nodule,  about  1  cm.  in  length,  which  rises  abruptly 
from  the  surface,  is  sharply  defined,  and  presents  slight  lobulation.  The  left  ureteral  orifice  is  normal,  but  the  right 
is  situated  in  the  center  of  a  lobulated  carcinomatous  nodule,  nearly  2  cm.  in  length.  Behind  this  are  several  other 
carcinomatous  outgrowths,  some  of  which  are  not  more  than  1  mm.  in  diameter.  The  bladder  mucosa,  except 
where  it  is  involved  in  carcinomatous  nodules,  is  normal,  .\bove  the  bladder  is  the  enlarged  myomatous  uterus, 
with  two  myomata  on  its  surface  and  numerous  small,  flat  carcinomatous  nodules  covering  the  peritoneum.  To 
the  right  is  the  dilate<i  right  ureter.  The  left  ureter  is  also  distended,  being  constricted  below  by  carcinomatous 
infiltration.      (After  Thoiiuis   S.   rulleii.i 

preceding.     The  pul.sc  was  110,  and  at   1  a.  m.  the  patient  wa.s  uncuii.scious  and 
gasping  for  breath.     She  died  at  2.10  a.  m. 

Aut.  No.  926.  The  body  is  that  of  a  colored  woman,  small  in  statui'e,  and 
somewhat  emaciated.  In  both  inguinal  regions  ai'e  prominent  nodnlar  swellings, 
the  largest  about  the  size  of  a  hen's  egg:  all  ai-e  IVeely  mowible.  and  tiie 
largest  gives  a  slight  fluctuation,  l^xteiiding  upward  to  the  inguinal  rings 
tire  indurated  ma.sses.  .Just  below  the  unibilicus  is  a  firm,  nio\able  mas.s, 
about  the  size  of  a  child's  head. 
26 


402  MYOMATA    OF    THE    UTERUS. 

The  right  lung  is  hound  ))y  fibrous  adhesions  to  the  chest-wall  at  about  the 
middle  third,  and  again  posteriorly  near  the  base.  The  parietal  pleura  on  the  right 
side  shows  a  grayish-white  nodule,  6  mm.  in  diameter,  and  there  are  small  groups 
of  similar  nodules  on  the  surface  of  the  diaphragm.  Where  the  lung  is  bound 
down  at  its  base  posteriorly  there  is  marked  induration,  due  to  superficial  meta- 
static tvnnor  deposits.  Thes(>  form  a  conglomerate  mass  of  small  round  nodules, 
which  are  beginning  to  undergo  .softening  in  their  centers.  On  section,  they  are 
of  a  uniformly  pale  yellow  color.  The  surface  is  dry,  but  the  central  portions 
are  soft,  and  can  be  readily  scjueezed  out.  There  are  also  five  similar  nodules 
scattered  over  the  surface  of  the  lung. 

The  left  lung  has  several  nodules,  each  about  1  cm.  in  diameter,  scattered 
over  its  surface. 

The  anterior  mediastinal  glands  are  not  enlarged,  but  the  bronchial  glands 
are  nuich  increased  in  size,  owdng  to  metastatic  deposits. 

Spleen  negative. 

The  liver  contains  no  metastases. 

The  kidneys  are  of  moderate  size;  the  capsules  strip  off  reatlily;  scattered 
over  the  surface  of  each  kidney  are  minute  clear  cysts. 

Both  ureters  are  dilated,  especially  the  left,  which  along  its  lower  third  is 
nearly  1  cm.  in  diameter;  at  the  junction  of  the  lower  and  middle  third  is  a  kink, 
above  which  the  dilatation  is  not  so  marked. 

On  opening  the  abdomen  a  portion  of  the  somewhat  fatty  omentum  was  found 
in  the  small  hernial  orifice  at  the  umbilicus ;  it  was  readily  withdrawn  by  gentle 
traction.     The  orifice  was  1.5  cm.  in  diameter. 

Both  la\-ers  of  peritoneum  are  smooth  in  the  upper  abdomen,  save  for  nodules 
about  the  size  of  peas,  which  here  and  there  stud  the  surface  of  the  intestines. 

The  ]:)rominent  and  enlarged  fundus  is  slightlv  adherent  to  the  parietal 
peritoneum  in  the  median  line  below  the  umbilicus.  The  peritoneum  in  the  lower 
part  of  the  abdomen  is  studded  with  single  or  grouped  whitish  nodules,  some  of 
which  are  as  large  as  ])eans;  the  tissue  on  both  sides  of  the  pelvic  brim  is  nuich 
thickened,  and  has  nodules  over  its  entire  surface. 

The  iliac  glands  are  enlarged,  one  on  the  left  side  reaching  about  4  cm.  in 
diaiiictcr,  and  in  its  center  c(mtaining  a  clear,  odorless,  straw-colored  fluid  look- 
ing much  like  urine.  The  smaller  glands  are  softened  in  their  central  portions. 
The  largest  inguinal  gland  on  the  left  side  contains  a  fluid  material  resembling 
creamy-white  pus.  The  glands  at  the  bifurcation  of  the  aorta  are  4  cm.  in  diam- 
eter and  necrotic.  The  mesenteric  glands  are  enlarged  and  necrotic,  as  are 
also  the  retroperitoneal  glands.  The  stomach  and  the  large  intestines  have 
small  white  nodules  scattered  over  their  peritoneal  surfaces. 

Frozen  sections  from  llie  small  nodule  in  the  ])osterior  inediastimun  show 
it  to  consist  of  dense  fibrous  tissue  infiltrated  with  broad,  irregular  plugs  of  e\)\- 
thelial  cells.  These  plugs  show  a  tendency  to  l)reak  down  in  their  central 
portions. 


AUTOPSY    FINDINGS. 


403 


1. 

f'A  .W^^  '^!& 


m 


The  \\\QY  shows  consklerable  fatty  degeneration,  especially  about  the  periph- 
ery of  the  nodules. 

Examination  of  the  Pelvic  Organs. — Path.  No.  1631.  The  uterus  is  con- 
verted into  a  large,  nodulated  tumor  mass,  approximately  21  x  17  x  15  cm. 
Projecting  from  the  fundus  anteriorly  is  a  large  rounded  boss,  8  cm.  in  diameter. 
Both  the  anterior  and  posterior  surfaces  also  present  similar  but  less  prominent 
elevations.  On  pressure,  these  nodules  are  firm  and  resistant.  Studding  the 
surface  of  the  uterus  are  small  flattened  tumors  or  confluent  masses  of  whitish, 
soft  material.  Covering  the  large 
nodules  are  tags  of  adhesions.  On 
cutting  open  the  uterus  a  large 
sloughing  cavity  is  found  (Fig. 
276);  this  is  14  cm.  in  length,  8 
cm.  in  its  greatest  diameter,  and 
includes  the  upper  part  of  the 
vagina,  the  broken-down  cervical 
canal,  and  the  greatly  enlarged 
uterine  cavity.  The  cervix  is 
represented  by  a  deep  excavation, 
whose  walls  consist  of  a  greenish, 
necrotic  material,  but  in  a  few 
places,  where  the  degenerative 
process  is  not  so  advanced,  a  pap- 
illary arrangement  of  the  tissue 
can  be  easily  recognized.  The 
new-growth,  which  has  evidently 
originated  in  the  cervix,  has  ex- 
tended to  the  vaginal  vault,  antl 
has  involved  to  a  moderate  degree 
the  rectum  and  bladder.  Project- 
ing into  the  uterine  cavity  are  sev- 
eral irregular,  dome-shaped  nod- 
ules, varying  from  1  to  o  cin.  in 
diameter.  The  entire  cavity  is 
lined  with  necrotic  tissue,  but  here 
and  there,  as  in  the  (■or\i\.  line  |)a|)illary  outgrowths  are  occasionally  visible. 

The  broad  ligaments,  mesosalpinx,  lub(>s,  ;uid  ovaries  are  studded  with 
isolated  or  condiiciit  masses,  wliicli  hit  w  I  litis!  i  in  color  and  soft  ;  tlicv  coi-i-cspoiid 
with  those  covering  the  surface  of  the  uterus.  Tlic  ovai'ics  ai'c  ncarh-  twice  the 
natural  size.  The  bladder  mucosa  is  evei-ywhei-e  sinootli.  hut  in  the  i-egion  of  the 
trigonum  is  a  whitish  elevation,  '1  cm.  in  dianietei-.  to  the  left  of  which  is  a  second 
but  smaller  one.      Both  of  these  are  tunioi-  ^I'owths  (fig.  277). 

Histologic     I'^xaniination.     Sections     IVoin    the    oi-i<i:inal    tumor    and     from 


Fig.  278. — Inv.\sion  of  k  Myom.\  by  \  Squamous-cellkd 
Carcinoma  of  the  Cervix.  (X  90  diam.') 
Gyn.  Path.  No.  16.31.  The  section  is  composed  of 
typical  myomatous  tissue  and  bunches  of  muscle-fibers  cut 
longitudinally  and  transversely,  and  separated  from  one 
another  by  connective  tissue  which  is  poor  in  nuclei.  .\t  a 
the  muscle-fibers  are  cut  obliquely.  At  b,  b,  and  b  typ- 
ical nests  are  seen,  composed  of  cells  that,  as  a  rule,  are 
uniform  in  size  and  contain  vesicular  nuclei.  At  c  is  a  row 
of  cancer-cells  lying  isolated  in  the  stroma  between  muscle- 
bundles.  .\  cross-section  of  such  a  row  gives  the  picture 
seen  at  d  and  e,  where  single  cancer-cells  are  visible.  The 
growth  also  forms  giant-cells,  as  seen  at  f.  where  there  is  a 
large  irregular  phujue  of  protoplasm  containing  a  lobulated, 
deeply  staining  mass  of  chromatin.  The  extension  to  the 
myoma  ha.s  been  by  continuity.     (.After  Thomas  S.  Cullen.) 


404  MYOMATA    OF   THE    UTERUS. 

various  points  show  tyijical  s(iuanious-('('llo(l  carcinoina.  They  also  show  quanti- 
ties of  ^•('l•y  large  cells  and  plaques  of  irregular,  deeply  staining  chromatin  lying 
loose  in  the  tissue  or  surrounded  by  large  masses  of  protoplasm. 

Definite  nests  arc  to  be  made  out  in  the  tubes  and  ovaries. 

Sections  from  the  myomata  show  that  the  carcinomatous  process  has  ex- 
tended by  continuity  into  them,  anil  that  various  portions  of  the  myoma  are 
being  replaced  by  nests  of  epithelial  cells  (Fig.  278). 

The  complete  histologic  findings  in  this  case  are  given  in  "Cancer  of  the 
Uterus,"  p.  139. 

Uterine  Myomata    Associated  with  Carcinoma  of   the   Body  of   the  Uterus 

Detected  at  Autopsy. 

All  these  patients  entered  the  hospital  too  late  for  any  extensive  operative 
]-)roc('dure;  in  fact,  some  of  them  died  shortly  after  admission. 

In  Aut.  No.  1605  the  anterior  uterine  wall  contained  a  myoma,  6x4x4  cm., 
while  tlie  l)ody  of  the  ut(>rus  was  the  seat  of  a  far-advanced  carcinomatous 
process  that  had  been  widely  disseminated  through  the  lymph-channels.  In 
this  case  the  myoma  played  an  important  role  in  the  differential  diagnosis, 
as  judged  by  the  bimanual  examination. 

The  uterine  enlargement  in  Aut.  No.  117  was  due  chiefly  to  the  presence  of 
the  myomata, — a  calcified  nodule,  3.5  cm.  in  diameter,  and  on  the  left  side  a 
myoma  19  x  15  cm., — the  carcinoma  being  relatively  small.  It  is  just  in  this 
class  of  cases  that  the  malignant  growths  escape  detection. 

In  Aut.  No.  505  the  uterus  contained  several  myomata,  the  largest  the  size 
of  a  hen's  egg.  In  this  case,  as  a  result  of  the  exploratory  laparotomy,  metastatic 
nodules  were  found  in  the  omentum  and  the  peritoneum  of  the  abdominal  wall. 
The  growth  in  the  uterus,  as  the  metastases  would  indicate,  was  far  advanced. 

The  clinical  ])icture  in  Aut.  No.  1407  was  confusing.  There  Avere  not  only 
several  myomata  and  a  carcinoma  of  the  body  of  the  uterus,  but  also  a  slough- 
ing submucous  myoma  and  a  pyometra.  Clinically,  the  sloughing  myoma, 
the  carcinoma,  and  the  pyometra  each  might  give  the  same  symptoms,  and  only 
on  an  examination  of  the  curettings  could  a  positive  diagnosis  be  established. 

Aut.  No.  1220  was  given  in  detail  in  Cullen's  "Cancer  of  the  Uterus,"  p.  466. 
When  I  saw  the  patient  in  consultation,  1  diagnosed  uterine  myomata  and  ad- 
vised hysterectomy.  When  the  ])atient  entered  the  hos])ital  a  few  days  later  it 
was  found  that  the  inguinal  glands  had  suddenly  enlarged,  and  as  the  possibility 
of  malignancy  was  thought  of,  I  advised  the  removal  of  an  inguinal  gland  for  ex- 
amination, not  wishing  to  subject  the  patient  to  an  alxlominal  operation  if  the 
growth  should  prove  to  be  malignant.  As  will  be  noted  from  the  history.  Dr. 
Stokes  found  the  inguinal  gland  the  s(>at  of  cysts  containing  papillomatous 
masses  identical  with  those  fomid  developing  in  tlie  ovary.  Tiie  ])atient  raj^dly 
lost  weight  and  soon  died. 

Not  until  autopsy  did  we  suspect  carcinoma  of   the  l)ody  of  the  uterus. 


AUTOPSY    FINDINGS.  405 

although  it  was  far  advanced  and  had  caused  wide-spread  metastases.  This  is 
another  example  of  the  manifold  pathologic  processes  that  may  be  present  in  the 
pelvic  organs  of  the  same  women. 

Undoubtedly,  the  most  instructive  in  our  series  is  Aut.  No.  277.  In  the  early 
days  of  our  myomectomy  operations  we  did  not  hesitate  to  remove  myomata, 
even  though  the  uterus  might  be  bound  down  by  adhesions.  In  this  case  a 
myoma  the  size  of  an  orange  was  removed  from  the  anterior  wall,  but  a  nodule, 
5  cm.  in  diameter,  in  the  posterior  wall  could  not  be  enucleated  on  account  of  ad- 
hesions. The  patient  died  on  the  sixth  day  of  peritonitis.  The  source  of  infection 
in  all  probability  was  the  adenocarcinoma  in  the  body  of  the  uterus,  which  was 
unsuspected  and  which  was  not  detected  until  the  autopsy. 

The  uterus  also  contained  a  small  subnmcous  myoma.  This  case  emphasizes 
the  extreme  care  that  must  be  exercised  to  determine  the  probable  condition 
of  the  uterine  mucosa,  and  also  that  of  the  tubes  when  myomectomy  is  con- 
templated. It  also  demonstrated  the  fact  that  a  submucous  myoma,  1.5  cm.  in 
diameter,  cannot  always  be  palpated,  even  when  the  uterus  is  carefully  (examined 
by  the  operator  after  the  al)domen  has  been  opened. 


Report  of  Cases  of  Uterine  Myomata  Complicated  by  Carcinoma  of  the  Body 
OF  THE  Uterus  as  Found  at  Autopsy. 

Gyn.  No.  2634.     Aut.  No.  505.      Path.  Nos.  204  and  222. 

A  d  e  n  o  c  a  r  c  i  n  o  m  a  o  f  the  b  0  d  y  o  f  the  u  t  e  r  u  s  ,  with  ex- 
tension of  the  g  r  o  w  t  h  t  o  the  uterine  myomata  (Fig. 
2  7  9);  secondary  involve  m  e  n  t  of  t  h  e  p  (m-  i  t  o  n  e  u  m  , 
the  inguinal,  j)  e  r  i  c  a  r  d  i  a  1  ,  bronchial,  a  n  d  c  e  r  ^'  i  c  ti  1 
1  y  m  p  h  -  g  1  a  n  d  s  ;  c  a  r  c  i  n  o  m  a  o  f  the  o  m  e  n  t  u  m  ;  c  h  r  o  n  i  c 
endocarditis  of  the  mitral,  a  o  r  tic,  a  n  d  t  r  i  c  u  s  p  i  d 
valves,  and  acute  e  n  d  o  c  a  r  d  i  t  i  s  of  the  mitral  valves. 
G  i  a  n  t  -  c  e  1  1  s  in  the  c  a  r  c  i  11  o  m  a  tons  g  1  a  n  d  s  . 

E.  S.,  ag(*d  fifty ;  colored.  Admitted  March  (>,  1SU4.  Coiiiplaiut .  abdominal 
enlargement,  with  soreness  in  the  region  of  the  umbilicus. 

The  ])atieiit  had  one  miscarriage  ten  years  ago,  but  has  had  no  children. 
Her  family  history  is  not  important,  and  with  the  exception  of  an  attack  of 
rheumatism  a  year  ago  she  has  always  been  well.  The  menstrual  history  is 
normal;   the  last  period  conimeiiced  I'Vbruai'y  22. 

In  the  lattei"  part  of  Decern  be  i',  I  S!);!,  she  began  to  complain  of  some  abdominal 
pain,  and  on  })Utting  her  hand  (»n  her  abdomen  discoN'ered  a  luni])  about  the  size 
of  the  end  of  the  finger  jusl  aboxe  the  innbilicus.  This  nodule,  which  was  at 
first  hard  and  non-seiisit i\'e,  has  gradual!}'  become  lai'ger,  mihI  is  now  (|uite  tender. 
The  patient  on  admission  is  faii'ly  well  nourished,  and  apart  from  the  abdominal 
enlargement,   feels  well. 

Operation,  March  10,  1S!)4.     h^xplorator}-  celiotomy.     On  opening  tiie  abdo- 


406  my():mata  of  the  uterus. 

men  the  peritont'iiin  was  fouiul  covered  with  numerous  small  nodules;  similar 
tumors  were  also  attached  to  the  intestines,  tubes,  ovaries,  and  to  the  posterior 
surface  of  the  uterus.  The  omentum  was  rolled  up,  forming  a  firm,  nodular 
mass  just  beneath  tiie  costal  margin.  The  peritoneal  cavity  contained  about 
2000  c.c.  of  turbid  fluid.  For  .several  days  after  the  oj)eration  the  patient  did 
well,  but  died  on  March  23. 

I'ath.  No.  204.  A  large  amount  of  dark-yellow,  nuiddy-looking  Huid  from 
the  abdominal  cavity,  and  two  .small,  papillary-like  masses  from  the  omentum, 
each  mea.suring  1x1  cm.,  were  sent  for  examination.  A  note  was  made  that 
similar  masses  were  attached  to  the  abdominal  wall,  intestines,  pelvic  organs, 
and  mesentery,  and,  in  fact,  to  the  peritoneum  everywhere. 

On  microscopic  examination  these  small  nodules  are  found  embedded  in 
adi])ose  tissue.  They  consist  of  glands  lined  with  one  layer  of  low  cylindric 
epithelium. 

In  many  of  the  cells  nuclear  figures  are  visible,  and  the  gland  epithelium  has 
proliferated  so  as  to  completely  fill  the  cavity.  The  stroma  between  the  glands 
is  moderate  in  amoimt  and  poor  in  cellular  elements.  The  picture  is  that  of  an 
adenocarcinoma. 

Aut.  No.  oOo.  Path.  Xo.  222.  An  abstract  from  the  protocol  is  as  follows: 
The  abdomen  is  somewhat  distended,  and  in  the  peritoneal  cavity  is  a  considerable 
accumulation  of  yelhjwish  serum.  Extending  completely  acro.ss  the  abdominal 
cavity,  in  the  I'egion  of  the  umbilicus,  is  a  large  tumor  mass  which  covers  the 
anterior  surface  of  the  transverse  colon.  This  tumor  is  lobulated,  light  in  color, 
and  opacjue.  It  corresponds  to  the  greater  part  of  the  omentum.  The  right 
eihfi^v  of  the  omentum  is  thicker  than  the  left ;  the  gastrocolic  portion  is  relatively 
free  from  tumor  involvement.  In  the  jjeritoneum.  at  the  hilum  of  the  s))leen.  are 
several  small  white  nodules;  the  lymphatics  around  the  jjortal  vein  also  contain 
small  nodules.  All  these  appear  to  Ijc  metastatic.  Covering  the  peritoneum 
and  the  large  intestine  are  numerous  metastases,  varying  from  a  millet  seed  to  a 
pea  in  size.  The}-  cover  the  peritoneum  everywhere,  and  are  especially  abundant 
in  the  pelvis.  The  lymi)h-glands  beneath  the  pericardium  are  enlarged  and  con- 
tain tumor  metastases.  The  vagina  and  cervix  are  apparently  normal.  The 
utei'us  contains  several  myomata,  the  largest  of  which  is  sul)mucous  and 
pedunculated,  being  the  .size  of  a  hen's  egg. 

The  muco.sa  covering  one-half  of  the  surface  of  this  nodule  is  congested  and 
hemorrhagic;  it  presents  a  mottled  ajjpearance  and  suggests  carcinoma.  The 
second  myoma  is  subperitoneal,  antl  also  appears  to  have  been  invaded  by  the 
tumor  occupjdng  the  uterus.  The  inner  surface  of  the  uterus  is  grayish  in  the 
upper  portion,  and  in  places  presents  a  yellowish  mottling.  The  muco.sa  ap- 
pears to  extend  foi'  some  depth  into  the  muscle.  The  ovaries  do  not  show  any 
involvement. 

Histologic  Examination. — Sections  from  the  uterus  show  that  the  nmscular 
coat  has  been  invaded  by  bunches  of  glands  which  are  small,  circular,  and  have 


AUTOPSY    FIXDIXGS.  407 

a  lining  of  cylindric  epithelium.  In  some  of  the  cells  two  or  more  nuclei  appear. 
A  few  of  the  glands  contain  giant-cells.  At  many  points  the  gland  epithelium 
has  proliferated  so  that,  instead  of  a  bunch  of  glands,  there  is  merely  a  large 
mass  of  cells  having  no  definite  arrangement.  The  centers  of  such  masses  often 
show  nuclear  fragmentation,  but  no  inflammatory  reaction.  The  myoma, 
which  is  involved  in  the  new-growth,  to  a  great  extent  has  undergone  hyaline 
changes.     The  principal   part  consists  of  hyaline  tissue,  with  here  and  there 


Fig.  279. — .\dknocarcinoma  ix  a  Myoma,   Skcondary   to   .^dknocarcixoma   oi    tiik   Body   ok   thk   Utkrts. 

(X  125diam.) 
Path.  No.  222.  Aut.  No.  505.  The  section  consi-st.s  of  tyi)ical  iiiyomatoiis  tissue.  The  majority  of  the 
muscle-fibers  have  been  cut  longitudinally,  and  wind  in  and  out  in  all  directions,  not  .showing  the  regular  arrange- 
ment so  characteristic  of  normal  uterine  muscle.  Moreover,  there  is  an  excess  of  connective  ti.ssue.  Scaftere<l 
abundantly  throughout  the  myoma  are  groups  of  carcinoma  cells.  In  the  majority  of  i)laces  they  appear  ij.s  glands 
lined  with  one  layer  of  cuboidal  epithelium  (a),  but  in  a  few  i)laces  the  glands  have  become  filled,  as  at  b,  or  the  cells 
form  large  solid  masses  as  .seen  at  c.  d  is  an  irregular  mass  of  cells  showing  a  tendency  to  branch.  On  the  whole, 
the  nuclei  of  the  epithelial  cells  are  fairly  uniform  in  size,  but  at  c  are  seen  a  few  large  nuclei.  The  growth  has 
extended  by  continviity.     (After  Thomas  S.  Cullen.) 

tufts  of  non-striped  nnisclc-iibci's.  ( Itlici- ])oitioiis  of  tlic  iiiyoiiin  coiil.'iiii  glanils 
arranged  singly  or  in  bunches.  Sonic  show  a  single  lumen,  while  othei-s  are  com- 
pletely filled  with  cells  (Fig.  279).  This  growth  is  merely  a  continuation  of  that 
in  the  uterine  muscle.  Portions  of  the  myoma  haxc  undergone  coagulation 
necrosis.  Just  beneath  the  capsule  of  the  lixcr,  and  attached  t(»  the  surface  of 
the  kidneys,  are  small  tumor  masses.  The  glands  of  the  neck  show  marked 
carcinomatous  involvement,  the  typical  glandular  type  being  here  well  preserved. 


408  MYOMATA    OF   THE    UTP:Rr.S. 

The  complete  histologic  descriiitioii  of  this  case  is  given  in  "Cancer  of  the  Uterus/' 

p.  434. 

Gyn.  No.  6439.  Aut.  No.  1220.  Path.  No.  2808. 

S  u  1)  ))  e  r  i  t  o  n  e  a  1  ami  interstitial  u  t  c  r  i  11  e  ni  y  o  ni  a  t  a 
(Figs.  280  and  281);  a  d  c  n  o  c  a  r  c  i  n  o  in  a  o  f  t  h  e  h  o  d  y 
of  t  h  e  u  t  e  i'  u  s  .  with  s  e  c  o  n  d  a  r  y  g  r  o  \v  t  h  s  in  the  p  c  r  i  - 
tone  u  in  .  o  in  c  n  t  u  ni  ,  in  e  s  e  n  t  c  r  y  ,  1  i  v  e  r  .  ])  a  n  c  r  e  a  s  ,  left 
adrenal  1  >  o  d  >•  ,  p  1  e  n  r  av,  and  lungs;  ) )  a  p  i  1  1  o  c  y  s  t  o  - 
m  a  t  a  of  1)  o  t  h  o  \'  a  r  i  e  s  .  with  extension  h  y  c  o  n  t  i  n  u  i  t  y 
to  the  c  0  r  r  e  s  J)  o  n  d  i  n  g  inguinal  glands;  h  y  d  r  o  s  a  1  - 
J)  i  n  X  in  the  inner  part  of  the  left  tube,  due  to  a 
kink,    t  h  e    fimbriated     e  x  t  r  e  in  i  t  y     h  e  i  n  g     ])  a  tent. 

M.  11.,  aged  fifty,  colored.  Admitted  October  14.  189S.  Complaint,  an 
abdominal  tumor  accomjianied  by  general  weakness. 

The  i)atient  has  been  inarrie(l  twenty-seven  years,  has  had  no  children  and  no 
miscarriages.  Menstruation  conunenced  at  twelve  years,  and  was  usuall}'  regu- 
lar, lasting  from  three  to  seven  days,  ])ut  always  excessive.  At  forty-one  the 
flow  ceased.  One  year  ago  a  hemorrhagic  discharge  commenced,  and  has  been 
))racti('ally  continuous.  For  many  years  there  has  been  an  irritating  leukorrheal 
discharge.     The  family  history  and  pre\'ious  history  are  unimportant. 

About  ten  years  ago  the  ]iatient  noticed  a  luni]).  about  the  size  of  an  egg,  in 
the  left  lower  abdomen.  This  was  not  painful  and  caused  no  inconvenience. 
In  August,  1897,  the  same  nodule,  although  not  enlarged,  became  quite  tender, 
and  the  patient  noticed  that  the  abdomen  at  times  was  somewhat  distended. 
As  above  noticed,  the  uterine  hemorrhage  began  at  this  time.  The  abdominal 
pain  has  been  more  or  less  constant  of  late,  sometimes  dull  and  aching  in  character. 
at  other  times  sharp  and  crainj)-like.  There  has  been  considerable  swelling 
of  the  lower  extremities  and  also  shortness  of  breath.  At  present  .she  is  ap- 
parently a  strong,  well-nourished  woman;  her  temperature  is  100.3°  F.,  the 
pulse  is  116.  The  bowels  are  constipated,  and  defecation  and  micturition  are 
painful.     The  lungs  and  heart  are  apparently  normal. 

October  10th.  The  abdomen  is  much  enlarged,  and  just  above  the  umbilicus 
measures  115  cm.  in  circumference.  The  most  prominent  point  lies  midway 
between  the  umbilicus  antl  the  ensiform  cartilage.  The  abdominal  wall  just 
above  the  pubes  is  much  thickened  and  j)endulous.  The  distance  from  the  umbili- 
cus to  the  pubes  is  18  cm. ;  from  the  umbilicus  to  the  ensiform  cartilage,  27  cm. ; 
from  the  right  anterior  superior  spine  to  the  umbilicus.  32  cm.;  from  the  left 
anterior  superior  spine  to  the  uml^ilicus,  32  cm. 

^'aginal  i^xamination. — The  labia  are  large  and  flabby.  The  vaginal  outlet 
admits  two  fingers,  and  it  is  just  j)ossil)le  to  touch  the  tip  of  the  cervix,  which 
lies  far  back  and  is  apparently  continuous  with  the  tumor  hlling  the  abdomen. 
Occupying  the  left  groin  is  an  immovable  mass,  6x3  cm.  This  has  a  somewhat 
elastic  feel,  and  suggests  a  metastasis. 


AUTOPSY    FIXDIXGS. 


409 


tint 


Fig.  280. — A  Lar(;e  Myomatous  Utkuis  t'lioKiNc  nu:  Pki.vis;  Small  Ovaiuan  Cv.sls  on  Both  Sidks;  Thick- 
ening AND  RkTRATTION  OF  THK  OmKNTUM.       MkTASTASKS  IN  THE  LiVKR  SKCONnARV  TO     AN  .\l)ENOCARCINOMA 

IN  THK  Body  of  thk  Uterus. 

Path.  No.  2808.  .\ut.  No.  1220.  Tlic  fiKUrc  sIidws  tlii'  appcurancc  nf  llu>  ;ilicl<iiiiiri:il  (Mvily  a.s  .seen  at 
autop.sy.  Filling  thei^elvis,  ami  projectinR  into  tlie  Kt'm'i'al  cavity,  is  a  laiKc  iricKular  niyitniatoiis  uterus  i  PiR.  281  V 
Springing  from  the  .surface  of  the  organ  are  large  and  .small  .sulii>eritoneal  myomata.  The  right  ttihe  is  seen  i)a.s.sing 
outward  in  a  depre.ssion  between  .several  of  the  largest  myomata.  On  the  right  side,  the  edge  of  a  small  ovarian 
cyst  is  .seen.  On  the  left  are  two  cysts  springing  from  the  left  ovary.  The  lower  otie  ha.s  very  thin  walls  and  is 
translucent.  On  the  left  a  loop  of  .small  intestine  ha.s  dropped  down,  and  hecome  firmly  a<lherent  to  the  growth 
in  the  inguinal  region.  Stuililing  the  nie.sentery  of  the  small  intestine  are  ininurc  uliitish  noilules,  which  are 
secondary  growths  from  the  adenocarcinoma  in  the  body  of  the  uterus.  The  lip  nf  ilie  vermiform  appendix  is 
also  embedded  in  carcinomatous  nodules.  As  a  result  of  cancerous  infiltration  the  omentum  is  drawn  up  and  forms 
a  dense  ma.ss  between  the  stomach  antl  tran.sverse  colon,  arul  just  l)elow  the  gall-blailder  the  ailipose  tissue  is  also 
greatly  involved.  Studding  the  right  lobe  of  the  liver  are  five  carcinomatous  nodules,  one  of  which,  even  in  the 
reduced  drawing,  is  nearly  1  cm.  in  diameter.  .Ml  are  sharply  <iclined,  whitish  in  color,  and  are  slightly  um- 
bilicated.  There  were  also  minute  nodules,  both  in  the  sul)stance  and  on  the  surface  of  the  organ.  The  hei)atic 
nodules  were  secondary  to  the  carcinoma  of  the  uterus.      i.\fter  Thomas  .S.  CuUen.) 


410  MYOMATA    OF    TH?:    UTERUS. 

Operation,  October  17.  1898.  Partial  excision  of  the  glands  in  the  left  in- 
guinal region.  Before  ()i)ening  the  abdomen  Dr.  I'h-nest  Stokes  thought  it  ad- 
visable to  explore  the  mass  in  the  left  inguinal  region.  As  soon  as  an  incision 
had  been  made  through  the  skin  over  the  most  })romiiu'ut  ])ortion  of  the  tumor, 
a  thin  watery  flukl  escaped.  Small  cysts,  lined  with  a  pale,  glistening  membrane, 
were  found  in  the  deeper  portions.  Many  of  these  contained  papillomatous 
masses.  In  the  face  of  such  findings,  associated  with  an  abdominal  tumor, 
it  was  deemed  advisable  to  abandon  any  furthci'  ()])eration.  A  small  drain  having 
been  placed  in  the  lower  angle  of  the  wound,  the  latter  was  closed.  The  patient 
recovered  satisfactorily  from  the  effects  of  the  slight  operation,  so  that  on 
October  29th  she  sat  uj)  in  a  wheel-chair.  The  lower  extremities,  however, 
gradually  became  edematous;  she  grew  weaker,  and  died  on  December  17,  1898. 

Aut.  No.  1220.  The  body  is  163  cm.  long;  rigor  mortis  is  not  marked.  There 
is  an  extreme  degree  of  edema  of  the  lower  extremities,  and  of  the  trunk  as  far 
as  the  shoulders.  The  al)domen  is  markedly  distended,  and  fluctuation  can  be 
elicited.  Filling  the  lower  part  of  the  alxlomen  is  a  large  tumor  mass,  while 
an  oval,  deeply  seated  tumor  is  found  in  the  left  inguinal  region  (Fig.  280). 
The  body  i)resents  an  anemic  appearance;  the  muscles  are  very  pale,  but  an 
abundance  of  adipose  tissue  is  present.  The  peritoneal  ca\dty  contains  about 
3000  c.c.  of  a  fairly  translucent,  yellow  fluid.  The  parietal  peritoneum  has  lost 
its  glistening  appearance,  and  over  a  large  area  is  covered  with  rough,  irregular, 
translucent  deposits.  This  condition  is  especially  marked  over  the  diaphragm 
and  over  the  right  side.  The  lx)wels  are  very  nmch  contracted  throughout 
their  entire  extent,  and  the  small  intestines  average  from  1.5  to  2  cm.  in  diameter. 
Studding  the  mesentery  of  the  small  intestines  are  many  small  white  tumor 
metastases;  the  mesentery  itself  varies  from  5  to  6  mm.  in  thickness.  On  the 
left  side  a  loop  of  ileum  is  adherent  to  the  large  tumor  filhng  the  lower  part  of  the 
abdomen.  The  omentum  is  drawn  up  and  contracted  into  a  firm  mass  between 
the  stomach  and  transverse  colon.  Everywhere  it  contains  tumor  deposits. 
Attached  to  the  rolled-uj:)  omentum  is  a  part  of  the  ileum,  which  makes  it  appear 
as  if  the  transverse  colon  ])asse;l  through  a  canal.  The  ascending  as  well  as 
the  descending  colon  is  firmly  adherent  to  the  posterior  abdominal  wall,  being 
bound  down  ])}•  tumor  inctastases.  Studding  the  intestine  at  various  jx)ints 
arc  small  tumor  nodules. 

The  pericardial  cavity  contains  a  slight  excess  of  cleai'  yellow  fluid,  but  there 
are  no  adhesions.  The  outer  muscle  is  rather  pale  and  soft:  its  vessels  are  tor- 
tuous. The  coronary  arteries  contain  yellow  patches  of  atheroma.  The 
pleural  cavities,  each  of  which  contains  400  c.c.  of  clear  yellow  fluid,  are  free  from 
adhesions.  Small,  translucent,  carcinomatous  nodules  are  found  on  the  costal 
pleura'. 

Both  lungs  are  emj)hyseniatous,  and  at  their  bases  show  marked  edema. 
Scattered  throughout  both  lungs  are  yellowish-white  tumor  masses,  some  reach- 
ing 1  cm.  in  dianietei-.     The   arteries  of  the  rijiht   lunij  contain  several  definite 


AUTOPSY    FIXDIXGS.  411 

organizing  thrombi.  Tlic  spleen  weighs  70  grams;  attached  to  its  surface  arc  a 
few  translucent  tumor  masses;  its  substance  shows  nothing  of  interest. 

The  liver  is  rather  small,  measuring  approximately  25x16x9  cm.  It  is 
pale;  the  surface  is  fairly  smooth,  whitish  in  color,  translucent,  and  somewhat 
umbilicated  (Fig.  280).  Several  of  the  nodules  are  cystic,  and  the  cyst-spaces 
contain  a  clear  reddish  fluid.  Numerous  nodules  and  cyst-like  spaces,  having 
corrugated  walls,  are  scattered  through  the  substance  of  the  organ.  There  are 
numerous  minute  nodules  on  the  surface  and  in  the  substance  of  the  liver.  On 
the  under  aspect  of  the  liver  the  nodules  are  surrounded  by  areas  of  congestion. 

The  periportal  glands  apparently  contain  metastases.  The  gall-bladder  is 
distended,  evidently  owing  to  pressure  at  its  neck,  resulting  from  implication  of 
the  adjacent  lymph-glands. 

Both  kidneys  present  the  usual  appearance,  but  on  the  surface  of  the  right 
kidney  is  a  small  tumor  nodule,  2  mm.  in  diameter.  The  ovaries  are  normal  in 
size.  The  right  adrenal  is  apparently  normal,  but  the  left  about  its  middle 
portion  contains  a  definite  tumor  nodule,  1  cm.  in  diameter.  The  pancreas  is 
enveloped  in  adhesions,  and  at  its  tail  contains  a  small  tumor  nodule.  The 
stomach  at  the  pyloric  orifice  is  surrounded  and  compressed  by  a  mass  of  enlarged 
glands;  the  greater  curvature  is  intimately  adherent  to  the  tumor  mass,  lying 
between  it  and  the  transverse  colon.  The  vermiform  appendix  in  its  last  2  cm.  is 
entirely  occluded  by  secondary  growths.  The  external  iliac  vein  on  the  left 
side  shows  a  partial  thrombosis.  Many  of  the  veins  below  Poupart's  ligament 
are  also  thrombosed.  The  right  femoral  vein  is  completely  occluded  l^y  a  firm 
thrombus,  ])ale  brown  in  color. 

In  the  inguinal  regions  the  large  tumor  masses  are  intimatel}'  connected  with 
the  veins;  the  mass  on  the  left  side  is  the  larger,  and  is  composed  of  many  cysts 
of  considerable  size,  from  which  a  slightly  turbid  fluid  escapes.  The  mass  on 
the  right  side  is  much  firmer.  The  thyroid  gland  on  both  sides  of  the  median  line 
is  much  enlarged.  A  lymph-gland  in  the  anterior  axillary  line,  10  cm.  below 
the  axilla,  contains  a  cystic  tumor.  The  boiic-maiTow  of  the  fciiiur  is  dark  red 
in  color,  but  fairly  firm.     The  brain  and  cord  are  apparently  normal. 

Path.  No.  2.S0S.  The  siH'ciinen  consists  of  the  jx'lvic  contents  and  of  tissue 
from  the  inguinal  region.  The  vagina  presents  the  usual  appearance,  and  the 
vaginal  portion  of  the  cervix  is  unaltered.  The  utei'us  measui'es  IS  \  \i\  \  i;>  cm. 
(Fig.  281).  The  anterior  surface  of  the  finidusand  the  post ei'ior  wall  are  studded 
with  myomatous  nodules,  varying  in  size  fi'om  that  of  a  pea  to  7  cm.  in  diameter. 
Nearly  all  tlie  nodules  ai'c  sessile.  Attached  to  the  ])ostcrioi-  surface  of  tlic  utci'us 
are  several  broad,  fan-like  a<lhesions.  The  uterine  walls  \ai-y  fi'oiii  .")  to  (>  cm. 
in  thickness,  owing  to  the  presence  of  inyoinatous  nodules,  which  are  sharply 
circumscribed  and  can  be  shelled  out  readily.  ( >iie  of  iheni  encroaches  to  a 
slight  extent  on  the  utei'ine  ca\-ity.  The  cer\'ical  canal  is  rathei'  shoil ,  but  the 
mucosa  ])resents  the  usual  appeai'ance.  The  uterine  ca\ity  is  12  cm.  in  length, 
and  the  nuicosa  in  the  lower  part  has  a  slightly  granular  appeai'ance,  due  to  the 


412 


MYOMATA    OF   THK    I'TERUS. 


Fig.  281. — .\n  Enlarged  .Myomatous  Uteris.     Adenocarcinoma  of  the  Body  of  the  Uterus.     Papillo- 

CYSTOMATA  OF  BoTH  OvARIES,  WITH  EXTENSION  BY  CONTINUITY  TO  THE  InGUI.N'AI.  GlANDS.        (g  nat.  size.) 

Path.  No.  2808.  Aut.  No.  1220.  The  bladder  is  contracted  but  normal.  The  uterus  is  much  enlarged,  irreg- 
ularly pear-shaped,  and  has  springing  from  its  surface  numerous  subperitoneal  myomata,  some  of  which  are  cal- 
cified. The  uterine  walls  are  greatly  thickened.  They  contain  many  small  interstitial  myomata.  The  vaginal 
mucosa  is  normal,  and  the  vaginal  jjortion  of  the  cervix  presents  the  usual  appearance.  The  cervical  mucosa  in 
the  lower  part  is  unaltered,  but  near  the  internal  os  the  mucosa  covering  the  posterior  wall  is  uneven  and  ro\ighened, 
owing  to  the  n\any  minute,  finger-like  processes  springing  from  the  surface.  In  the  body  of  the  uterus  the  normal 
mucosa  is  no  longer  recognizable,  being  replaced  by  a  ragged  looking  gnjwth,  from  the  surface  of  which  spring 
myriads  of  delicate,  finger-like  processes.  The  growth  is  whitish  in  cohjr,  friable  in  appearance,  and  ha-s  invaded 
the  uterine  muscle  to  a  marked  degree;  in  jilaces  it  c<)mi)letely  encircles  the  myomatous  nodules.  .\t  another  level 
it  was  found  penetrating  some  of  the  myomata,  and  had  extended  almost  to  the  iieritoneal  surface,  a  distance  of 
fully  5  cm.  On  the  right  side  a  small  portion  of  an  ovarian  cyst  can  be  seen.  Springing  from  the  outer  and  inner 
surfaces  of  these  cysts  are  papillary  ma.sses,  the  papillary  growth  extending  by  continuity  into  the  inguinal  glands. 
On  the  left  side  is  a  small,  nuiltilocular  ovarian  cyst,  from  the  inner  surface  of  which  arise  papillary  growths. 
The  marked  thickening  and  infiltration  of  the  left  inguinal  region  are  due  to  papillary  growths  in  the  left  ovary. 
A  section  through  the  thickened  area  would  show  large  and  small  cyst-like  spaces  containing  tree-like  ingrowths. 
(After  Thomas  S.  Cullen.J 


AUTOPSY    FINDINGS.  413 

.short,  finger-like  outgrowths.  In  its  upper  })ortion  the  cavity  shows  no  normal 
mucosa.  The  walls  are  somewhat  ragged,  and  are  implicated  in  a  new-growth 
which  in  places  infiltrates  the  tissue  to  a  depth  of  at  least  5  cm.,  penetrating  the 
entire  thickness  of  the  uterine  wall.  The  growth  consists  of  delicate  trabeculse, 
in  the  meshes  of  which  is  a  fine,  crumbly  material. 

The  right  tube  is  9  cm.  long,  considerably  curved,  and  throughout  the  greater 
part  of  its  course  lies  in  a  depression  between  the  myomatous  nodules.  It  aver- 
ages 1  cm.  in  diameter,  and  has  a  patent  fimbriated  extremity.  The  ovary  is 
converted  into  a  semicystic  tumor,  6  cm.  in  diameter.  Its  outer  surface  is  in 
places  covered  by  adhesions,  but  springing  from  it  at  several  points  are  delicate 
papillary  projections  or  warty  outgrowths.  On  section,  the  tumor  is  seen  to  be 
made  up  to  a  great  extent  of  large  and  small  thin- walled  cysts.  The  semisolid 
portion  consists  for  the  most  part  of  a  somew^hat  friable  papillary  growth,  which 
projects  into  the  cyst  cavities.     The  contents  of  the  smaller  cysts  are  gelatinous. 

The  left  tube  is  8  cm.  in  length,  averages  6  mm.  in  diameter,  and  terminates 
in  an  occluded  fimbriated  extremity.  Its  outer  surface  is  covered  with  dense 
adhesions  that  bind  it  to  the  posterior  surface  of  the  uterus.  On  more  careful 
examination  it  is  found  that  the  point  of  occlusion  is  situated  a  short  distance 
from  the  fimbriated  extremity  of  the  tube,  and  that  the  fimbriae  are  free;  then 
w^e  have  a  hydrosalpinx,  and  at  the  same  time  a  patent  outer  extremity.  The 
occlusion  is  due  to  dense  adhesions. 

Springing  from  the  outer  pole  of  the  ovary  is  a  smooth-walled  cyst,  5  cm.  in 
diameter.  Its  walls  vary  from  1  to  2  nmi.  in  thickness;  its  anterior  surface  is, 
for  the  most  part,  smooth,  but  over  an  area  2.5  x  2  cm.,  and  corresponding  to  the 
ovarian  attachment,  large  clusters  of  papillomatous  masses  project  into  the 
cavity.  Springing  from  the  small  portion  of  the  ovary  that  remains  are  similar 
outgrowths. 

The  bladder  mucosa  presents  the  usual  appearance,  and  no  changes  can  be 
noted  in  the  rectum.  Both  broad  ligaments  are  markedly  thickened,  and  areas  of 
induration  can  be  traced  down  to  and  are  directly  continuous  with  the  growths 
in  the  inguinal  region.  On  pressure  they  are  somewhat  elastic.  The  entire 
inguinal  growth  on  the  left  side  on  section  is  found  to  consist  of  cyst-like  s])aces, 
some  fully  5  cm.  in  diameter,  which  contain  a  gelatinous  material.  Springing 
from  the  partitions  between  the  cysts  are  complicated  i)apillary  outgrowths. 
Such  sections  remind  one  very  much  of  a  ])apillocystoma  of  the  ovary. 

Histologic  examination  demonstrated  that  the  growth  involving  the  iinicr 
walls  of  the  uterus  was  a  typical  adenocarcinoma,  and  that  this  had  given  rise  to 
wide-spread  metastases  especially  prominent  in  the  liver.  The  tumors  on  either 
side  of  the  uterus  were  ])apillocystoniata,  ovarian  in  origin.  The  growth  on  the 
left  side  had  extended  by  continuity  to  the  inguinal  glands.  For  the  complete 
histologic  picture  in  this  case  sec  "Cancer  of  the  Uterus,"  p.  468. 

This  case  is  of  importance  on  account  of  the  intimate  I'elal  ioiishij)  between 
the  mvomata  and  the  ;u  lei  loearci  noma.      Im'oiii  I  he  clinical  e\a  mi  nation  ah  )iie  the 


414  MYOMATA    OF    THK    ITKRUS. 

case  would  have  been  considered  as  one  of  niyomata.  Still  more  interesting  is 
the  coexistence  of  the  carcinoma  of  the  body  of  the  uterus  and  of  papillocystomata 
of  both  ovaries.  When  an  incision  was  made  over  the  prominence  in  the  left 
inguinal  region,  the  papillary  nature  of  that  growth  was  clearly  perceptible  to  the 
naked  eye;  and  even  if  one  had  previously  thouglit  of  the  possibility  of  an  adeno- 
carcinoma of  the  uterus,  the  mintl  would  have  been  entirely  set  at  rest  on  that 
point,  inasmuch  as  uterine  carcinomata  originating  in  the  cervix  or  body  never 
give  rise  to  such  metastases.  The  combination  of  the  uterine  myomata,  the  ad- 
enocarcinoma of  the  body  of  the  uterus,  and  the  papillocystomata  of  both  ovaries 
is,  of  course,  merely  a  coincidence.  It  may  be  well,  however,  to  remember,  when 
considering  the  advisability  of  removing  an  ill-defined  pelvic  tumor,  that  inde- 
pendent malignant  growths  may  exist  in  the  uterus  and  ovaries  at  the  same  time. 

Gyn.  No.  8147.     Aut.  No.  1605. 

Anatomic  Diagnosis.  —  M  y  0  m  a  and  a  d  e  n  o  c  a  r  c  i  n  o  m  a 
of  the  bod}-  of  the  uterus;  metastases  in  the  lymph- 
glands  and  adjacent  peritoneum,  p  1  e  u  r  se  ,  medi- 
astinal glands,  and  s  j)  1  e  e  n  ;  extension  into  the  b  r  o  a  tl 
ligament;  chronic  endocarditis  of  the  aortic  and 
mitral  v  a  1  \'  e  s  ;  cardiac  hypertrophy;  edema  and  con- 
gestion of  both  lungs;  infarction  of  right  kidney; 
d  o  u  1)  1  e  h  \'  ( I  r  o  u  r  e  t  e  r  ;  general  arteriosclerosis; 
perisplenitis. 

The  peritoneal  cavity  contains  about  600  c.c.  of  a  deep  red  fluid,  mostly  blood. 
The  surface  of  the  peritoneum  is  smooth.  The  uterus  is  markedly  enlarged. 
Occupying  the  anterior  wall  of  the  uterus  is  a  rounded  myoma,  6x4x4  cm., 
which  distorts  considerably  the  shape  of  the  organ.  Projecting  from  the  fundus 
behind  the  first  tumor  is  a  second  smaller  mass,  which  merges  gradually  with  the 
body  of  the  uterus.  Situated  upon  the  anterior  surface,  and  also  upon  the  ad- 
jacent surface  of  the  bladder,  are  small,  firm,  grayish-white  masses,  with  irregular 
and  slightly  nodular  surfaces.  Similar  nodules  arc  present  in  the  posterior  cul- 
de-sac  and  in  the  wall  of  the  rectum.  The  uterus  is  9  cm.  in  length,  and  on  section 
the  tumor  in  the  anterior  wall  proves  to  be  a  typical  myoma.  The  cavity  of  the 
uterus  is  7  cm.  in  length  and  1.5  cm.  in  width.  It  contains  freshly  coagulated 
blood,  and  the  walls,  es])e('ially  the  posterior  portions,  are  irregular  and  ragged. 
Extending  from  the  cavity  and  occupying  the  entire  fundus  and  greater  portion 
of  the  posterior  wall  is  a  soft,  grayish-white  tumor  mass,  in  many  places  studded 
with  o])aque  yellowish  areas.  There  is  marked  thickening  of  the  broad  ligament, 
and  the  tubes  and  o^'aries  are  densely  adherent  to  the  uterus,  but  there  are  no 
adhesions  to  the  wall  of  the  pelvis.  Both  ureters  are  embedded  in  the  thick- 
ened broad  ligament  and  show  some  slight  dilatation.  Examination  of  the  wall 
of  the  rectum  shows  that  the  tumor  masses  nuMitioiied  alxive  have  invaded  only 
the  serous  and  nmscular  coats. 


AUTOPSY    FIXDIXGS.  415 

Microscopic  examination  of  the  tumor  mass  in  the  funtlus  shows  it  to  be  an 
adenocarcinoma. 

Gyn.  No.  7102.     Aut.  No.  1407. 

Adenocarcinoma  of  the  Ij  o  d  y  of  the  uterus  associ- 
ated with  subperitoneal  and  s  u  1)  m  u  c  o  u  s  uterine  m  y  o  - 
m  a  t  a  . 

L.  R.,  aged  fifty-three.  Autopsy,  August  18,  1899.  Anatomic  diagnosis: 
adenocarcinoma  of  the  uterus;  sloughing  submucous  myoma ;  pyometra;  suppu- 
rating parametrium;  vaginal  implantation  with  carcinoma;  extension  to  the  peri- 
toneum and  the  surface  of  pleura;  thrombosis  of  the  femoral  veins;  embolic 
plugging  of  both  pulmonary  arteries;  infarction  of  the  right  lung ;  thrombosis  of 
the  vesical  veins;  cardiac  hypertrophy  and  dilatation;  chronic  diffuse  nephritis 
(small  granular  kidney) ;  cholelithiasis. 

The  abdominal  cavity  contained  a  large  amount  of  fluid.  The  intestines  were 
slightly  matted  together,  the  coils  being  studded  with  small  tumor  nodules.  The 
uterus  was  globular,  extended  12  cm.  above  the  symphysis,  and  was  adherent  to 
the  abdominal  wall.  The  tubes  and  ovaries  were  buried  in  adhesions.  The 
uterus  was  pear-shaped,  measuring  18  x  14  cm.  The  bladder  was  adherent  to  it. 
Attached  to  the  uterus  at  the  cornu  was  a  ])edunculated  myoma,  3  cm.  in  diam- 
eter. Similar  but  smaller  nodules  were  found  on  the  posterior  surface  of  the 
uterus.  The  uterine  cavity  was  full  of  grayish-looking  pus.  The  mucous  mem- 
brane was  2.5  cm.  in  thickness,  and  apparently  had  grown  into  the  uterine  wall. 
The  appearance  strongly  suggested  carcinoma.  Scattered  throughout  the  uter- 
ine wall  were  numerous  submucous  myomata,  the  largest  6  cm.  in  diameter,  and 
sloughing. 

Histologic  examination  showed  the  growth  to  be  a  typical  adenocarcinoma. 

Gyn.  No.  278,     Aut,  No.  117. 

C  a  r  c  i  n  o  m  a  o  f  t  h  c  bod  y  o  f  t  li  c  u  t  e  r  us  a  s  s  o  c  i  a  t  e  d 
w  i  t  h  large  an  d  s  m  a  1  1   u  t  e  r  i  n  c   in  y  o  m  a  t  a  . 

M.  L.  K.,  white,  aged  sixty-five.  Admitted  .July  13,  1890.  The  i)atient  has 
had  no  children  and  no  miscarriages.  The  iii('n()])ause  was  passed  about  fifte(Mi 
yearsago.  For  the  last  year  she  has  complained  of  aconstant  bloody  vaginal  How 
and  of  pain  in  the  back,  and  during  the  last  four  months  of  ])ain  in  the  right  groin. 
She  has  noticed  swelling  of  the  feet  and  ankles  for  the  last  we(>k.  l-'illing  the 
lower  part  of  the  abdomen  is  an  oblong  mass,  apiinrcntiy  adiicicnt  lo  the  ab- 
dominal wall,  ^riic  umbilicus  is  slightly  rctiactcd.  The  \aginal  outlet  is  in- 
tact; the  cervix  is  small.  The  pelvis  is  full  of  small  nodules.  The  patient  has 
been  delirious  for  the  last  few  days.  The  urine  contains  a  considerable  amount 
of  albumin. 

Aut.  No.  117  (July  27,  1890).  On  the  anterior  wall  of  the  uterus  is  a  partly 
calcified  myoma,  3.5  cm.  in  dianuMer,  and  on  the  lel'l  side  a  inyoina.  l!»x  I.")  cm., 


416  MVOMATA    OF    THK    ITHRUS. 

grayish  in  color.  Tiiis  tiiinor  is  easily  shelled  out  from  the  uterus.  The  left  tube 
is  dilated  and  elongated.  It  is  4  cm.  in  diameter  and  24  cm.  in  length.  The 
right  tube  is  likewise  closet! ;  it  is  2  cm.  in  diameter  and  18  cm.  in  length.  The 
body  of  the  uterus  contains  several  fungus-like,  friable  masses,  and  the  upper 
part  of  the  cavity  is  filled  with  ])rojections  resembling  villi  over  an  area  5  cm.  in 
diameter. 

Histologic  examination  shows  the  growth  to  be  a  tyijical  carcinoma  of  the 
body  of  the  uterus.  The  autopsy  was  an  incomplete  one,  but  sufficiently  thor- 
ough to  show  that  there  were  a  chronic  diffuse  nej)hi-itis  and  hypertrophy  of  the 
left  ventricle  of  the  heart. 

Gyn.N0.1173.     Aut.  No.  277. 

I  n  c  o  m  p  1  e  t  e  m  y  o  m  e  c  t  o  m  y  ,  o  n  e  n  o  d  u  1  e  having  been 
removed,  others  left  behind  on  account  of  dense  ad- 
hesions. Death  resulted  f  r  o  m  general  peritonitis. 
Unsuspected  carcinoma  of  the  body  of  the  uterus 
was   found    at    a  u  t  o  j)  s  y  . 

A.  B.,  single,  aged  forty-three,  colored.  Admitted  January  26,  1892.  Men- 
struation began  at  fourteen,  was  regular.  ])ainful.  ])r()fuse,  and  lasted  from  three 
to  four  days.  Three  and  one-half  weeks  ago  the  i)atient  noticed  a  lump  in  the 
left  iliac  region.  For  a  few  months  previous  she  had  had  some  pain.  In  No- 
vember, 1891,  in  New  York,  she  had  two  small  myomata  removed  by  the  vagina. 
At  the  present  time  tliert^  is  a  growth  down  in  the  right  ovarian  region,  and  the 
patient  has  a  slimy,  wat(>ry  vaginal  discharge,  with  occasional  burning.  She 
is  very  anemic. 

Vaginal  Examination. — The  outlet  is  relaxed.  The  cervix  is  near  the  outlet 
and  is  intact.  Filling  the  entire  pelvic  cavity  is  a  hard  and  innnovable  mass, 
a  nodular  portion,  the  size  of  two  fists,  occupying  the  left  side  of  the  pelvis. 

Operation,  February  13,  1892.     Myomectomy. 

The  uterus  apparently  contained  two  myomatous  masses,  the  anterior  one  the 
size  of  an  orange,  the  jjosterior  one  a  little  larger.  After  the  release  of  a  few 
intestinal  and  omental  adhesions  the  anterior  myoma  was  enucleated.  The 
posterior  one  could  not  be  shelled  out  on  account  of  the  dense  adhesions. 

The  patient  vomited  a  great  deal  after  the  operation.  The  abdomen  soon 
became  distended;  the  pulse  grew  ra])i(l,  and  the  tem])(>rature  rose  to  103°  F.  on 
the  fifth  day,  but  (Iropi)e(l  to  101..")°  F.  on  the  sixth.  The  patient  at  this  time 
was  covered  with  a  cold,  clammy  sweat;  .>^he  voided  her  urine  involuntarily, 
and  died  on  the  same  day.     She  had  definite  signs  of  peritonitis. 

Aut.  No.  277.  Anatomic  diagno.sis:  Acute  ))urulent  ))eritonitis  following 
abdominal  myomectomy;  subpci'itoncal  and  sul)inucous  utei'ine  myomata;  un- 
suspected carcinoma  of  the  body  of  the  uterus;  general  arteriosclerosis;  cardiac 
hypertrophy;  chronic  diffuse  nei)hritis;  emphysema  of  both  lungs;  bronchopneu- 
monia of  the  right  lung. 


AUTOPSY    FIXDIXGS.  417 

In  the  peritoneal  cavity  is  a  considerable  accinnulation  of  tiirljid  fluid  that 
has  a  decidedly  fecal  odor.  There  are  slight  intestinal  adhesions.  In  the  pelvic 
cavity  is  a  sloughino;  area  correspomUng  to  the  point  of  niyoniectoniy.  The  tubes 
and  ovaries  are  bound  down  by  adhesions.  The  uterine  cavity  is  fihed  with 
sloughing  tumor  masses,  which  seem  to  be  infiltrating  the  uterine  wall.  The 
cervix  is  free.  Scattered  throughout  the  uterus  are  several  small  myomata. 
Sections  from  the  uterine  wall  revealed  adenocarcinoma  of  the  body.  Cultures 
from  the  peritoneal  cavity  showed  a  pure  growth  of  Staphylococcus  pyogenes 
aureus. 

Carcinoma  of  the  Rectum  Associated  with  Uterine  Myomata. 

In  one  of  these  cases  the  carcinoma  was  situated  in  the  sigmoitl  flexure. 
Both  ovaries  were  the  seat  of  C3'stic  tumors,  and  the  uterus  contained  myomata. 
In  this  case  fatal  peritonitis  developed.  On  p.  392  is  described  in  detail  a  case 
in  which  a  carcinoma  of  the  sigmoid  was  accidentally  discovered  after  the  re- 
moval of  a  large  m^^omatous  uterus.  A  portion  of  the  bowel  w'as  resected, 
and  the  patient  lived  for  several  months. 

In  the  second  case  here  tlescriljed  the  myomatous  uterus  was  large.  One 
ovary  was  the  seat  of  an  abscess,  and  all  the  tissues  were  densely  matted  together 
by  pelvic  adhesions.  Examination  of  the  rectum  revealed  a  carcinoma  involving 
the  entire  lumen  of  the  bowel,  situated  1  cm.  from  the  anal  orifice.  In  neither  of 
these  cases  was  an  operation  feasilile. 

Gyn,  No.   12656.     Aut,  No.  2671. 

Carcinoma  of  t  h  e  s  i  g  m  o  id  flex  u  r  e  ,  u  t  e  i'  i  n  e  m  y  o  - 
m  a  t  a  ,  b  i  1  a  t  e  r  a  1  a  d  e  n  o  c  y  s  t  o  m  a  t  a  o  f  t  h  e  o  \'  a  r  }•  ;  sec- 
ondary   p  e  r  i  t  o  n  i  t  i  s  . 

E.  C,  colored,  single,  aged  thirty.  Admitted  January  25;  died  February 
8,  1906.  The  patient  has  com|)lained  of  ))ain  in  th(>  abdonuMi  for  the  past  three 
years.  At  present  she  has  four  or  five  stools  daily,  which  show  the  ])resence  of 
blood.  This  sym])t()m  has  been  noted  for  nearly  a  year,  although  the  patient 
has  no  hemorrhoids.     She  appears  to  be  very  ill,  and  is  extremely  emaciated. 

A  week  after  admission  to  the  hospital  there  was  considerable  abdominal 
distention,  and  a  rather  definite  tumor  mass  could  be  felt  in  the  i-ight  hypo- 
gastrium.  She  died  fi\-e  days  later.  On  account  of  the  extreme  weakness  a 
satisfactory  examination  could  not  be  made. 

Aut.  No.  2()71.  Anatomic  diagnosis:  l^ilateral  o\arian  adenoe\-stoniata ; 
multiple  utei'ine  myomata  :  carcinoma  of  the  sigmoid  flexure:  ])erl oral  ion  ol  the 
bowel;    gangrenous  peritonitis. 

The  contents  of  the  abdominal  cavity  are  ci-owded  high  up  into  the  cavity 
by  two  large  tumor  masses  which  extend  upwai'd  from  the  peb'is:  one  lying 
in  the  median  line  extends  to  l.o  cm.  above  the  synii)hysis  ])ubes:  the  second 
lies  in  the  left  flank  an<l  extends  to  the  costal  border.      Between  the  two  masses 


418  MYO.MATA    OF   THE    UTERUS. 

is  a  cavity  containing  a  tarry,  iirccnish-hlack  material,  with  a  mixture  of  blood 
and  havino;  a  distinctly  gangrenous  odor.  The  tumor  masses  are  covcMvd  with  a 
thick  fi]:)rous  membrane  outside  the  capsule,  which  apparently  represents  a 
reflected  peritoneal  fold.  The  intestines  are  bound  down  to  the  tumor  masses 
by  fibrous  adhesions,  and  to  each  other  by  a  firm  fibrinopurulent  exudate. 
The  diai)hragm  reaches  to  the  third  rib  on  tlu'  right  side,  and  to  the  fourth  inter- 
space on  the  left.  The  ])elvic  viscera  and  tumor  masses  were  removed  in  one 
mass.  On  section,  the  uterus  seems  normal  in  size;  it  has  been  pushed  forward 
and  to  the  left  by  the  tumor.  Rising  from  its  fundus  is  a  pedunculated  tumor, 
7.5  X  4  cm.  in  diameter.  This  tumor  is  slightly  lobulated;  it  is  firm,  and  on 
section  shows  interlacing  l:)undles  of  tissue  in  a  somewhat  translucent  back- 
gi-()vmd.  A  similar  but  smaller  tumor,  measuring  2.5  x  1.5  x  1  cm.,  lies  just 
beneath  the  serosa.  In  the  anterior  surface  of  the  uterus  a  third  tumor,  8.5  cm. 
in  diameter,  is  ])resent.  They  all  })resent  the  typical  myomatous  a])pearance. 
The  large  tumor  masses  described  earlier  are  attached  to  the  uterus  l)y  an  ovarian 
ligament;  one  occupies  the  position  of  the  right  ovary,  the  other  the  left.  The 
mass  corresponding  to  the  right  ovary  measures  19  x  12  x  12  cm.  It  is  firm, 
and  on  section  has  a  light  yellowish-pink  color,  and  on  close  inspection  is  seen 
to  have  a  honey-combed  structure,  the  surface  showing  many  small  cavities, 
1  to  o  mm.  in  diameter,  containing  colloid  material.  The  cut  surface  is  some- 
what uniform  in  appearance.  The  capsule  has  Ix^en  in  no  way  invaded  by  the 
growth.  The  mass  in  the  position  of  the  left  ovary  measures  15  x  10.5  x  10  cm.; 
in  the  upjx'r  part  of  the  tumor  it  abuts  on  the  gangrenous  peritoneal  cavity 
mentioned.  This  cavity,  which  appears  as  a  deep  ragged  space,  is  filled  with 
foul-smelling,  softened,  grayish-black  material.  Except  for  this  and  a  somewhat 
general  greater  degree  of  softness,  this  tumor  resembles  that  found  in  the  sigmoid 
flexure.  There  is  a  fungating  tumor  mass  in  the  bowel,  16  cm.  from  the  anal 
opening.  This  mass  is  made  up  of  numerous  large  nodules  of  irregular  shape, 
])rojecting  into  the  lumen — at  one  })oint  for  a  distance  of  2.5  cm.  These  masses 
surround  a  crater-like  depression  where  there  has  been  a  perforation  of  the  in- 
testinal wall.  The  pcM'foration  leads  ui)ward  between  the  tumor  masses  into  the 
cavity  above  described.  On  section  of  the  tumor  mass  the  muscular  coat  of  the 
intestine  is  foimd  to  be  invaded  by  a  somewhat  opa(|ue  growth.  Al)ove  the  ulcer- 
ation the  intestine  is  dilated  and  its  mucosa  shows  numerous  ulcers.  Its  wall 
is  hypertrophied. 

Microscopic  examination  of  the  uterine  nodules  shows  them  to  be  typical 
myomata  without  degeneration.  Sections  from  the  solid  portions  of  the  ovarian 
cysts  show  the  tumors  to  be  made  up  of  alveoli  containing  a  colloid  material. 
The  alveoli  are  lined  with  a  singli'  layer  of  uniformly  staining  epithelial  cells. 
Portions  of  the  section  show  some  necrosis,  but  no  signs  of  malignancy  are 
present.  In  one  necrotic  area  there  is  leukocytic  invasion.  Sections  from  the 
tumor  in  the  sigmoid  flexure  show  the  growth  to  consist  of  large  alveoli  lined  with 


AUTOPSY    FIXDIN'G.S.  419 

irregularly  shaped  and  stained  cells,  lying  usually  in  a  single  row.     The  growth 
has  invaded  the  muscular  coat  as  far  as  the  peritoneum. 

This  case  is  very  interesting  on  account  of  the  multiplicity  of  the  pathologic 
processes  detected  in  the  pelvis.  Not  only  are  thtnv  the  myomatous  uterus, 
and  the  large  ovarian  cysts,  but  also  the  carcinoma  of  the  sigmoid  flexure, 
which  in  itself  would  have  been  suflficient  to  cause  death. 

Gyn.  No.  562.     Aut.  No.   172. 

Carcinoma    of    the    r  e  c  t  u  m  ;    uteri  n  e    m  y  o  m  a  t  a  . 

J.  Z.,  white,  admitted  February  3;  died  February  17,  1891.  The  patient 
is  forty-eight  years  of  age.  She  has  been  married  twenty  years,  but  has  never 
been  pregnant.  The  menstrual  periods  have  been  regular  during  the  past  year. 
The  patient  complains  of  pain  in  the  left  flank,  with  alternating  attacks  of  con- 
stipation and  diarrhea,  with  occasional  bloody  stools.  She  has  lost  considerably 
in  weight  during  the  past  two  years.  During  this  same  time  she  has  suffered  con- 
siderably from  pain  and  diarrhea,  but  these  symptoms  have  been  especially 
troublesome  during  the  past  three  months.  During  the  past  six  months  blood 
has  frequently  been  found  in  the  stools.  In  the  past  three  months  there  has 
been  pain  in  the  left  iliac  region,  and  also  in  the  lower  abdominal  zone.  Palpation 
in  this  region  elicits  consideral)le  tenderness.  On  vaginal  examination  the  uterus 
is  found  to  be  markedly  enlarged,  hard,  and  fixed;  it  fills  up  the  whole  lower 
portion  of  the  pelvic  cavity.  On  manipulation  a  free  bloody  discharge  comes 
from  the  uterus.  Owing  to  marked  tenderness,  examination  is  exceedingly  difli- 
cult. 

Aut.  No.  172.  The  pelvic  viscera  were  removed  en  ina.sse.  Douglas'  pouch 
was  obliterated  by  fibrous  adhesions  between  the  rectum  and  the  uterus.  The 
inner  wall  of  the  rectum,  1  cm.  from  the  anus,  is  occupied  by  an  ulcerated  new- 
growth  which  implicates  the  entire  circumference  of  the  bowel  and  is  7  cm.  long. 
The  ulcerated  surface  of  the  growth  is  whitish ;  its  margins  are  ele\-ated  and  of  a 
soft,  grayish  appearance;  intermingled  are  areas  of  henu^rrhage.  The  whole 
presents  a  crater-like  appearance.  The  wall  of  the  rectum  has  been  entirely 
destroyed.  Over  the  central  ulcerated  area  it  measures  5  cm.  in  iliamclri-.  The 
muscular  wall  of  the  rectum  is  hy))ertro))hied  al)ove  the  growth. 

The  posterior  wall  of  the  uterus  is  hrmly  emheddcd  in  adhe.^ions  to  the 
cancerous  part  of  the  bowel,  and  is  the  seat  of  s('\-eral  intci-stitial  myomata.  The 
largest  on  th(>  right  side  is  5  cm.  in  diameter.  There  is  a  soft,  pedunculated  sui)- 
mucous  myoma,  1.")  cm.  long,  and  in  the  right  lateral  vaginal  wall  a  cyst.  4  cm. 
in  diametei'.  The  left  ovar}-  contains  an  abscess  7  x  S  cm.,  and  tVom  it  esca])es 
green,  foul-smelling  pus. 

Cultures  from  the  abscess  of  the  ovary  show  a  colon-like  b.-u-ilhis,  and  sections 
from  the  rectal  tumor  prove  that  it  is  an  adenocarcinoma  of  the  bowel. 


420  .MYUMATA    OF   THE    UTERUS. 

Sarcomatous  Transformation  of  Myomata  Detected  at  Autopsy. 
In  only  one  case  was  a  j)riniary  sarcoma  (Ictcctcd  in  a  myoma  at  autopsy. 
(Gyn.  No.  OO-io.  Aut.  No.  lOSo.)     This  case  was  carefully  described  by  the  late 
Dr.  J>ouis  I.ivin^ood.  and  is  given  in  detail  (page  224)  with  a  series  of  similar 
growths  detected  at  ojx'ration. 

Sarcoma  of  the  Bladder  Associated  with  Uterine  Myomata. 
As  this  condition  is  exceetlingly  rare,  a  short  history  of  the  case  is  given. 

Gyn.  No.  832.     Aut.  No.  211. 

L.  G.,  aged  forty,  coloi'ed.  Admitted  to  the  Johns  Hopkins  Hosi)ital  June 
24;  died  July  12,  LS91.  She  had  been  married  twent^'-five  years  and  had 
had  four  children  and  one  miscarriage.  For  the  previous  month  she  had  been 
complaining  of  incontinence  and  painful  micturition.  The  urine  was  very  strong 
in  odor  and  of  a  dirty,  muddy  color,  and  material  resembling  grit  had  been  passed. 
These  pieces  at  times  were  as  large  as  beans.  She  had  complained  of  pain  in 
the  lower  part  of  the  abdomen  for  the  last  two  months,  and  said  that  it  burned 
like  fire.     She  had  had  fever  and  chills,  and  had  lost  in  weight. 

The  patient  on  admission  appeared  anemic  and  had  a  worn  expression.  The 
abdomen  was  slightly  swollen,  and  she  complained  of  sudden  attacks  of  pain. 
On  examination  the  outlet  was  found  to  be  relaxed,  th(>  anterior  vaginal  wall 
was  tense  and  sensitive,  and  there  was  a  mass  the  size  of  a  closed  fist  just  behind 
the  symphy.sis.  It  moved  up  and  down  in  the  pelvis  and  had  a  markedly  solid 
feeling.  The  uteru-^  was  retroflexed.  The  patient  gradually  lost  ground,  and 
died  July  12,  1891. 

Aut.  Xo.  211,  July  1.3th.  Anatomic  diagnosis:  Sarcoma  of  the  bladder,  no 
metastases;  extensive  diphtheric  cystitis,  pyehtis,  some  pyelonephrosis,  espe- 
cially of  the  left  kidney,  chronic  diffuse  nephritis,  apparently  limited  to  the  left 
kidney,  moderate  atheroma,  slight  cardiac  hypertrophy,  moderate  i)ulmonary 
emphysema,  uterine  myomata. 

The  l)la(lder-walls  are  much  thickened,  measuring  on  an  avcTage  0.8  to  1  cm. 
in  thickness.  The  muscular  coats  are  hypertrophied.  The  nnicous  membrane 
of  the  bladder  has  been  almost  entirely  rejjlaced  by  exten.-^ive  dij^htheric  u1c(t- 
ation.  From  the  inner  surface  of  the  bladder  j^roject  several  soft,  grayish-white 
masses.  The  free  surface  in  some  places  is  covered  with  a  slight  opacjue  grayish- 
white  necrotic  tissue,  and  the  tissue  beneath  is  almost  homogeneous,  appearing 
like  mucous  membrane.  The  growths  vary  in  size  from  O.'A  to  1 .5  cm.  in  diameter, 
and  project  in  places  as  far  as  1  cm.  into  the  bladder.  11iey  have  broad  basal 
attachments,  and  arc  most  ;diuiidaiit  in  the  jiosterior  wall  of  the  bladder,  near 
its  middle  portion.  The  vaginal  mucosa  is  ('(mted,  over  a  large  part  of  its  extent, 
with  a  grayish,  coherent  false  membrane,  which  in  ))laces  can  be  scraped  off  without 


AUTOPSY    FIXDIXGS.  421 

loss  of  substance,  while  in  other  places  the  mucosa  itself  seems  to  be  nothing  more 
than  necrotic  membrane. 

The  uterus  is  7  cm.  long  antl  contains  in  its  walls  myomata,  the  largest  of 
which  is  2  cm.  in  diameter.  The  myomata  are  submucous,  interstitial,  and  sub- 
peritoneal.    The  left  ovary  and  tube  are  surrounded  by  old  adhesions. 

Histologic  Examination. — The  free  surface  of  the  bladder  growth  is  covered 
with  a  necrotic  layer  containing  many  bacilli  and  some  chromatin  particles.  The 
new-growth  is  composed  of  closely  packed  cells,  varying  in  size  and  shape. 
In  general  they  are  large  and  somewhat  fusiform,  not  mistakable  for  smooth 
muscle-fibers.  In  other  places  there  are  epithelioid  cells,  round,  oval,  or  poly- 
gonal in  shape.  There  are  also  cells  with  large,  well-staining  vesicular  nuclei, 
and  a  protoplasm  that  is  somewhat  granular.  The  cells  in  the  growth  are 
separated  from  one  another  by  a  scant  amount  of  a  finely  hbrillated  sul^stance. 
Sometimes  the  cells  occur  in  clumps,  apparently  in  lymph-spaces,  but  there  is  no 
regular  alveolar  arrangement.  Strands  of  the  same  kind  of  tissue  extend  out 
between  the  bundles  of  smooth  muscle  tissue,  or  they  often  spread  out  into 
the  layers.  This  invasion  of  the  muscle  extends  in  places  throughout  the  entire 
thickness  of  the  bladder-wall,  but  the  main  mass  of  the  tumor  lies  inside  of  the 
muscular  coat,  in  the  situation  of  the  mucosa  or  submucous  coats,  which  are  not 
to  be  recognized. 

The  tumor  is  a  mixed  large-celled  sarcoma,  with  a  predominance  of  large 
fusiform  cells,  often  arranged  in  bundles,  especially  along  the  blood-vessels. 
The  presence  of  the  uterine  myomata  in  association  with  sarcoma  of  the 
bladder  is,  of  course,  a  mere  coincidence. 


Tuberculosis  of  the  Uterus  Associated  with  Myomata. 
There  was  only  one  case  in  which  tuberculo.sis  of  the  uterus  coexisted  with 
uterine  myomata.  In  Aut.  No.  136  on  a  patient  thirty-two  years  of  age  i)ul- 
monary  tuberculosis  was  found.  The  mcscnlci'ic  glands  were  implicated.  In 
the  left  uterine  cornu  was  a  myoma,  3  cm.  in  diameter,  that  showed  areas  of 
degeneration.  The  Ixjdy  of  the  uterus  was  occujjied  by  a  gi'ayish  mass  which 
projected  into  the  canal,  and  scattered  throughout  it  were  tubercles.  In  this  case 
the  tuberculous  j)rocess  in  the  uterus  was  undoubtedly  secondary  to  the  pulmon- 
ary lesion. 


Autopsies  in  which  Heart  Lesions  were  Found,  possibly  Attributable  to 

Uterine  Myomata. 

We  have  two  cases  in  which  it  seeiiKnl  that  the  niyomata  directly  or  indirectly 
had  been  responsible  for  the  cardiac  lesion.  In  the  one  case  tlieic  wcic  \-ege- 
tations  on  the  heart-valves;  in  the  oilier.  (legenerati\-e  changes  wei-e  found  in 
the  heart   muscle. 


422  ]\IY<)MATA    OF   THE    UTERUS. 

Gyn.  No.  6185.     Aut.  No.   11 12.     Path.  No.  2441. 

M  u  1  t  i  ))  1  ('  111  y  0  111  a  t  a  o  f  the  u  t  e  r  u  s  ,  wit  li  one  large 
sloughing  s  u  h  111  u  c  o  u  s  n  o  d  11 1  e  .  A  c  u  t  e  vegetative 
a  o  r  t  i  e  and  mitral  endocarditis;  septic  infarction 
of  the  left  lung,  acute  localized  j)  1  e  u  r  i  s  y  ,  old 
[)  1  e  u  r  i  t  i  c  adhesions,  chronic  interstitial  splenitis, 
subacute  glomerular  nephritis,  recent  miliary  ab- 
scesses in  the  renal  pyramids,  chronic  adhesive 
pelvic     J)  e  r  i  t  o  n  i  t  i  s  . 

The  j)atient  was  fifty-four  years  of  age,  colored.  Admitted  June  21; 
died  June  2o,  1898.  She  was  in  a  precarious  condition,  and  had  to  be  operated 
u])on  at  once.  On  examination  under  ether  an  ovoid  tumor  was  found  pro- 
jecting from  the  vulva.  It  was  yellowish  l)rown  or  greenish  in  color,  and  cystic. 
It  had  a  ])edicle  2.  5  cm.  in  diameter,  and  sprang  from  the  cervix  on  the  left  side. 
A  smaller  and  similar  mass  was  also  seen  projecting  from  the  cervix.  The  uterus 
was  the  size  of  that  of  a  four  months'  pregnancy,  hard,  and  fixed  in  the  pelvis. 
The  pulse  was  very  rapid,  and  the  temperature  101.8°  F.  The  submucous 
nodules  were  removed  in  the  usual  way,  but  the  j^atient  steadily  grew  worse. 
Her  maximum  temperature  on  the  day  of  her  death  was  106.2°  F. 

Aut.  No.  1112.  The  myomatous  uterus  was  found  firmly  bound  down 
in  the  pelvis  by  numerous  adhesions.  The  aortic  and  mitral  valves  were  the  seat 
of  fresh  vegetations.  Septic  infarction  was  found  in  the  left  lung,  and  there  were 
evidences  of  old  adhesions  in  the  pleural  cavity. 

The  kidneys  were  the  seat  of  a  subacute  inflammation,  and  as  evidences  of 
the  recent  infection  miliary  abscesses  were  found  in  the  pyramids  of  the  left 
kidney.     The  offending  organism  was  Staphylococcus  pyogenes. 

Path.  No.  2441 .  The  submucous  nodule  removed  from  the  uterus  at  operation 
was  12  cm.  long  and  7  cm.  in  diameter.  Its  surface  was  slightly  roughened; 
otherwise  it  presented  the  typical  myomatous  appearance.  Sections  from  the 
surface  of  the  tumor  showed  no  trace  of  mucosa.  The  surface  was  covered  with 
polymorphonuclear  leukocytes  and  necrotic  tissue.  Beneath  was  a  very  vascular 
zone,  comjiosed  of  large  and  small  blood-vessels.  So  abundant  were  these  blood- 
vessels that  in  j)laces  they  occupied  half  the  field.  Some  of  the  vessels  contained 
organizing  thronil)i.  The  surrounding  stroma  showed  considerable  hemorrhage, 
but  was  covered  with  many  polymorj^honuclear  leukocytes.  The  tumor  was 
composed  of  non-striated  muscle-fibers  running  in  various  directions.  It  was  an 
ordinary  siihmucous  myoma,  the  surface  of  which  had  become  necrotic  and  had 
gradually  disintegrated.  In  this  case  a  general  infection  had  ])r()bably  developed 
ironi  the  sloughing  submucous  myoma,  and  might  account  for  the  vegetations  on 
the  cardiac  valves  and  for  the  recent  miliary  abscesses  in  the  kidney. 


AUTOPSY    FIXDIXGS.  423 

Gyn.  No.  77.  Aut.  No.  69. 

M  y  0  111  a  of  the  uterus  with  central  11  e  c  r  o  s  i  s  ,  p  y  o  - 
nephrosis  due  to  \)Y  e  s  sure  on  the  ureters.  Chronic 
passive  congestion  of  the  lungs,  d  i  s  ji  1  a  c  e  m  e  n  t  of  t  he 
diaphragm  and  a  b  d  o  111  i  n  a  1  viscera  b  }'  pressure  of  the 
tumor,  hypertrophy  and  hyaline  degeneration  of  the 
heart  (Figs.  282  and  283). 

An  abstract  of  the  case  reported  by  Dr.  Ernest  K.  Cullen  in  the  Johns 
Hopkins  Bulletin,  1906,  vol.  xvii,  p.  267,  is  quoted  here: 

The  patient  was  admitted  January  6,  1890.  No  satisfactory  history  could 
be  obtained  on  account  of  her  condition.  She,  however,  first  noticed  a  tumor 
in  the  abdomen  about  four  years  ago.  This  had  gradually  increased  in  size.  The 
abdominal  wall  was  uniformly  distended  by  a  large  tumor,  which  on  palpation 
presented  two  smaller  nodules  in  the  lower  abdominal  zone.  The  patient  had  a 
slight  but  exceedingly  fetid  vaginal  discharge.  She  was  examined  by  Dr. 
Osier,  who,  apart  from  the  pressure  symptoms  due  to  the  tumor,  found  nothing 
abnormal.     The    patient   gradually  grew  weaker   and  died  on  January   31st. 

Aut.  No.  69.  The  uterus  is  19  cm.  in  length,  anteflexed,  and  occupies 
the  anterior  portion  of  the  tumor.  The  tumor  is  nodular,  and  divided  into  two 
distinct  lobes.  On  section,  it  presents  a  triangular  cavity,  which  at  its  base 
measures  11  cm.  It  is  filled  with  a  slightly  blood-stained  fluid,  and  dense  masses 
of  firm  Avhite  elastic  tissue.  The  lymphatics  in  the  lower  abdomen  are  greatly 
dilated  and  contain  a  brownish  colored  fluid. 

The  left  kidney  is  enormously  dilated  and  turned  toward  the  front.  The  cap- 
sule is  adherent.  The  surface  is  irregular  and  lobulated.  Beneath  the  capsule 
are  numerous  whitish  areas,  while  surrounding  the  kidney  are  jiurulent  foci. 
The  pyramids  are  flattened.  The  pelvis  is  generally  smooth  and  hard,  and 
covered  with  a  fibrinopurulent  exudate.  The  ureters  are  dilated  and  closely  ail- 
herent  to  the  posterior  surface  of  the  tumor.  The  right  kidney  is  about  th(> 
same  size  as  the  left,  and  presents  essentially  the  same  features. 

The  liladder  mucosa  shows  ecchymoses,  is  dee})ly  injected,  and  contains  a 
small  amount  of  turbid  urine. 

The  heart  is  slightly  enlarged,  and  weighs  245  grams.  The  pericardial  surfaces 
are  smooth.  With  the  exce))ti()n  of  a  slight  contraction  of  the  mitral  orifices, 
the  valves  appear  to  be  normal.  .\  few  i)ale  ])atches  are  seen  scattcicd  throughout 
the  cndocardiuiii.  The  wall  of  the  left  vent  i-icic  iiicasurcs  17  1111 11.,  and  that  of  the 
right  4  mm.  in  thickness.  The  heart  muscle  is  tolenibly  lii'iii  and  dark  brown 
in  color.  On  section  of  the  left  ventricular  wall,  small  foci  arc  visible  immediately 
beneath  the  endocardium.     The  orifices  of  the  coi-onary  Mitci'ics  aic  dihitcd. 

Histologic  appearances  of  the  heart  iiiusch'.  Scattered  throughout  the  wall 
of  the  left  ventricle,  especially  near  tiie  endocardium,  ai'e  numerous  isolated 
groups  of  opaque,  deeply  staining  fibers,  which  ajipear  to  have  undergone  calci- 


424 


MYOMATA    OF   THE    UTERUS. 


fication  (Fig.  282).  These  areas  are  composed  of  adjacent  fibers  ranging  in 
nunibc^r  usually  from  three  to  twelve.  Such  fibers  in  most  instances  are  well 
defined,  but  occasionally  appear  irregular  in  outline,  as  if  disintegrating.  They 
have  lost  both  t  heir  cross  and  longitudinal  striations,  and  appear  rather  homogene- 


.^.7  -       -i-       ^ 


^•^•,.., 


•y^^.'i^SLikS 


Fig.  282. — C.\i.t  iii.  vi  lus   ut    hik  IIi-.aki   Musci.k  As>im  iai  kd  uiki   L  ilium-.  Myomata.      (X  125  diam.) 

Aut.  No.  69.     The  dark  areas  represent  calcifietl   muscle-fibers.     The  most  characteristic  of  these  are  indicated 

by  a.     The  stroma  between  the  muscle-fibers  shows  some  small-cellefl  infiltration,     (.\fter  Ernest  K.  Cullen.) 

ous  and  opa(iue,  staining  deeply  with  iiiethylene-blue  and  hematoxylin.  No 
nucleus  is  discernible  within  the  fiber,  but  fine,  small,  oval  or  round  nuclei  are  situ- 
ated about  it.  In  the  interventricular  septum  the  process  appears  to  be  much 
less  extensive.  Single  fibers  (Fig.  283)  are  observed,  which  present  a  homogeneous, 
granular  tippearance,  and  with  the  cosiii  stain  ai'c  differentiated  fn^m  the  sur- 


AUTOPSY    FINDINGS.  425 

rounding  fibers.  Sucii  fihci's  ai'c  stained  faintly  hi'own  in  color,  and  the  nucleus 
is  absent.  Definite  calcification  is  observed  in  small  groups  of  fibers  which, 
in  general  appearance,  resemble  those  in  the  wall  of  the  left  ventricle.  In  sections 
taken  from  other  parts  of  the  heart  no  alteration  of  the  fibers  was  visible. 

At  the  time  of  the  autopsy  Professor  Welch  studied  the  microchemical 
reaction  of  these  altered  fibers  in  the  fresh  specimen,  and  found,  on  the  addition 
of  glacial  acetic  acid  to  those  fibers  which  contained  a  highly  refractive  substance, 
a  slow  dissolution  of  this  material  without  the  evolution  of  gas.  This  refractive 
material  dissolved  I'apidly  in  hydrochloric  and  nitric  acid,  also  without  the 
evolution  of  gas.     As  it  dissolved  the  fibers  sw(>]1(h1  and  lost  their  refractive 


*3» 


"<C> 


^ 


I       .^v  a  :.^ 


Vv 


'■^p 


-  r  --    '  V 


\  I 
a 

Fig.  283. — Hyaline  Degeneration  of  Heart  Muscle,  .'Associated  with  Uterine  Myomata.     (X  650  diam.") 
Aut.  No.  69.     The  section  is  from  the  interventricular  septum.     Some  of  the  muscle-fibers  (a)  have  imdergone 
typical  hyaline  degeneration,  and  the  stroma  surrounding  them  shows  some  small-round-celled  infiltration,     (.\fter 
Ernest  K.  CuUen.) 


property  and  appeared  h\'aliiu'.  This  suljstancc  was  insoluble  in  strong  caustic 
])otash  and  ammonia.  In  the  frozen  section  left  onci-  night  in  an  atiucous 
solution  of  potassium  dichromate  the  refract i\c  iiiatci-ial  dissolved  slowly.  The 
most  interesting  reaction  was  obscixcd  in  the  spccinicn  treated  with  strong 
sulphuric  acid.  The  refracti\'e  matei'ial  changed  without  the  eNolution  of  gas 
into  beautiful  clumj^s  and  rosettes  of  naiiow,  I'hombic  crystals  of  calcium  sul- 
phate. Smaller  crystals,  usually  single,  ap|)eai'ed  in  the  fluid  close  by,  but  no 
such  reaction  was  ex'ideiiced  in  specimens  fi-oiii  otliei'  ]>ai1s  ot  the  heai't. 

Ernest  Culleii  says  fuiiher:  "The  etiolog\"  of  the  cell  neeiosis  in  this  case 
cannot  be  definitely  determined,  but  it  is  possible  that  the  etiologic  factor  con- 
cerned in  the  })roduction  of  the  existing  pyoiiephi-osis  may  also  be  responsible 


426  MYOMATA    OF   THE    UTERUS. 

for  the  lesion  in  the  inyocardiuni.  The  pressure  exerted  upon  the  heart  by 
the  large  abdominal  tumor  may  also  have  entered  into  the  causation." 

As  noted  in  the  history,  no  definite  account  of  previous  illness  could  be 
obtained.  The  myoma  caused  pressure  on  the  ureters,  infection  followed,  and 
then  necrosis  in  the  heart  muscle,  with  subsequent  deposit  of  calcium  salts.  It 
it  ([uite  iH)ssil)le  that  if  no  myoma  had  existed  no  pyonephrosis  would  have 
developed,  and  consequently  no  cardiac  lesion  would  have  followed.  In  any 
event  the  presence  of  the  myoma  was  a  predisposing  factor. 

In  neither  of  these  cases  is  there  clear  presumptive  evidence  that  the  myomata 
were  responsible  for  the  cardiac  lesion,  but  the  clinician  will  certainly  gather 
the  impression  that  if  the  myoma  had  been  removed  several  years  before,  the 
danger  of  cardiac  lesion  would  have  been  materially  less. 


Death  Due  Directly  to  Myomata. 

All  surgeons  are  familiar  with  the  marked  pallor  seen  in  patients  suffering 
from  continued  and  severe  hemorrhages  when  submucous  myomata  are  present, 
and  also  with  the  elevation  of  temperature  and  other  septic  phenomena  which 
accompany  foul-smelling  and  sloughing  submucous  myomata. 

In  Clyn.  No.  11337  the  jxitient  entered  the  hospital  complaining  of  weakness 
and  loss  of  blood.  Her  hemoglobin  was  only  12  per  cent.,  and  she  died  within 
four  (lays.  The  autopsy  findings  were  those  that  might  have  been  expected 
aftci-  excessive  hemorrhage. 

In  Gyn.  No.  6185  the  symptoms  were  those  of  exhaustion  from  hemor- 
rhage, combined  with  sepsis  due  to  absorption  from  the  foul,  sloughing  submucous 
myoma:  the  secondary  cardiac  and  pulmonary  foci  were  a  natural  sequence  to 
the  local  necrotic  and  sloughing  myoma. 

A  study  of  Gyn.  No.  10337  shows  that  the  j)atient  was  suffering  from 
emaciation  and  marked  toxemia,  evidently  in  large  measure  due  to  a  slough- 
ing submucous  nodule.  Both  kidneys  contained  retention  cysts.  These  probably 
hastened  the  patient's  d(>ath,  but  the  changes  may  lik(>wise  have  been  primarily 
due  to  the  myoma. 

In  the  fourth  ca.se,  Gyn.  No.  77,  there  were  a  fetid  discharge  from  the 
vaginti  and  central  necrosis  of  one  of  the  myomata.  The  abdominal  contents 
had  been  nmch  displaced  by  the  tumor,  and  the  ureteral  dilatation  was  caused 
by  pressure  exerted  by  the  tumor.  In  this  case  the  death  was  in  all  prol)al)ility 
itiimcdiatcly  due  to  the  pus  kidney,  but  primarily  to  the  tumor. 

A  careful  ])erusal  of  these  cases  will  certainly  convince  the  reader  that  if  th(i 
myomata  had  not  been  present,  or  if  they  had  been  removed  before  the  nodules 
had  become  submucous,  the  outlook  for  the  patients  would  have  been  greatly 
inqjroved. 


autopsy  p^ixdixgs.  427 

Cases  in  which  Myomata  Caused  Death. 

Gyn.  No.  11337.      Aut.  No.  2319. 

Intramural  myoma;  hemorrhage  from  the  uterus; 
extreme  secondary  anemia;  fatty  degeneration  of 
the  heart  and  other  organs;  focal  necroses  in  the 
liver;  double  hydrosalpinx;  ovarian  cysts;  healed 
infarct  of  spleen. 

B.  H.,  colored,  aged  thirty-eight.  Admitted  June  6;  died  June  10,  1904. 
She  complained  of  weakness  and  bleeding. 

She  was  married  ten  years  ago,  but  has  had  no  children.  Six  months  ago  she 
began  to  have  hemorrhages.  The  flow  lasted  about  three  weeks.  From  that 
date  there  has  been  almost  constant  bleeding,  and  she  has  been  in  bed  for  three 
months.  WTien  the  bleeding  is  not  present,  there  is  a  very  foul  discharge.  The 
patient  is  very  weak  and  short  of  breath.  There  is  considerable  nausea  and 
vomiting.  The  mucous  membranes  are  ver}'  pale ;  the  hemoglobin  is  12  per  cent. 
Red  blood-corpuscles,  1,828,000.  In  making  a  blood  examination  the  patient 
bled  so  much  from  the  prick  in  her  ear  that  compresses  had  to  be  put  on  to 
stop  the  bleeding.     Adrenalin  had  no  effect. 

Vaginal  Examination. — A  mass  is  felt  extending  a  hand 's-breadth  above  the 
symphysis.  The  cervix  is  smooth  and  normal.  There  is  a  mass  the  size  of  a 
cocoanut  occupying  the  fundus. 

The  patient  gradually  lost  ground,  and  died  the  fourth  da}^  after  her  admission. 
Her  temperature  varied  between  102°  F.  on  admission  and  103°  F.  on  the  second 
day;  on  the  fourth  day,  the  day  of  her  death,  it  reached  normal.  The  uterine 
cavity  was  irrigated  and  packed  with  gauze,  but  this  procedure  did  not  in  any 
way  check  the  bleeding. 

At  autopsy  it  was  found  that  the  uterus  contained  three  myomata.  The 
chief  bleeding  had  come  from  the  submucous  myoma,  and  there  were  marked 
anemia  of  the  various  organs,  fatty  degeneration  of  the  heart,  and  focal  necroses 
in  the  liver. 

In  this  case  the  death  seems  to  have  Ix'cn  due  primarily  to  the  excessive 
uterine  hemorrhages. 

Gyn.  No.  10337.      Aut.  No.  2088. 

L'  t  e  r  i  n  e  m  y  o  m  a  t  a  with  a  s  1  o  u  g  h  i  11  g  sub  m  u  c  o  u  s 
n  o  d  u  1  e  ;  m  a  r  k  e  d  e  m  a  c  i  a  t  i  o  n  a  n  d  p  r  o  t'  o  u  11  d  t  o  x  c  m  i  a  . 
R  e  t  e  n  t  i  o  n     cysts     in     the     k  i  d  11  c  y  s  . 

J.  McC,  aged  forty,  colored.  Admitted  March  17:  dic.l  Marcii  22.  I<)03. 
Her  history  was  obtained  from  her  sister-in-law,  as  the  jinliciit  was  unconscious. 
Fifteen  years  ago  she  had  an  attack  of  tyi)liniil  U'vrv  ;iMd  was  insane.  Re- 
covery took  place  after  two  montiis.  Since  then  she  has  been  a  little  <|ueer  at 
times.    Ten  years  ago  an  abdominal  tumor  was  first  noticed.     This  has  grown 


428  MYOMATA    OF   THE    FTKRUS. 

slowly.  Tlirt'e  weeks  ago  she  was  taken  ill,  Init  no  further  history  could  be 
ehcited. 

On  admission  she  was  very  irrational  and  much  emaciated.  The  temperature 
was  96°  F. ;  the  pulse,  100.  She  was  di-owsy  most  of  the  time,  apparently  pro- 
foundly toxemic.  The  hmg-sounds  were  normal.  There  was  a  loud  systolic 
murmur  at  the  apex,  transmitted  to  the  axilla  and  over  the  entire  chest.  The 
abdomen  was  .'symmetrically  enlarged  below  the  umbilicus,  and  on  the  upper 
surface  of  the  tumor  were  three  nodules.  The  patient's  condition  gradually 
grew  worse,  and  she  died  five  days  after  admis.sion. 

At  autopsy  a  sloughing  subnuicous  myoma  was  found,  and  the  uterus  also 
contained  numerous  nodules.  In  both  kidneys  retention  cysts  were  encountered. 
There  were  marks  of  old  rachitis,  and  apparently  nmcoid  degeneration  of  the  sul)- 
epicardial  fat. 

Grayish  opaque  flecks  were  found  in  the  myocardium. 

In  this  case  the  cause  of  death  seems  to  have  been  the  sloughing  sul)mucous 
myoma,  a.ssociated  with  the  results  of  pressure. 

Tor  the  details  of  Gyn.  No.  6185  (Aut.  No.  1112)  seep.  422,  and  for  the  findings 
in  Gyn.  No.  77  (Aut.  No.  69)  see  p.  423. 

Summary  of  the  Autopsy  findings  in  which  Uterine  Myomata  were  Present. 
The  following  tabulation  gives  the  more  essential  autopsy  findings  as  viewed 
from  the  surgeon's  standpoint: 

Tuberculosis  of  the  Fallopian  tube  associated  with  uterine  myomata  (Aut.  No. 

189S) 1  case. 

Carcinoma  of  the  ovarj'  (primary)  associated  with  uterine  mj'omata  (Aut.  Nos. 

474  and  1.371) 2  cases. 

Sarcoma  of  the  bladder  associated  with  uterine  myomata  (Aut.  No.  211) 1  case. 

Carcinoma  of  the  sigmoid  flexure  associated  with  uterine  myomata   (Aut.   Nos. 

172  and  2671) 2  cases. 

Tuberculosis  of  the  uterus  associated  with  uterine  myomata  (Aut.  No.  136) 1  case. 

Carcinoma  of  the  cervix  associated  with  uterine  myomata  (Aut.  Nos.  689,  926) ....  2  cases. 
Carcinoma  of  the  body  of  the  uterus  associated  with  myomata  (Aut.  Nos.  117,  277, 

505,  1220.  1407,  1605) 6  cases. 

Sarcomatous  transformation  of  uterine  myomata  (Aut.  No.  1085) 1  case. 

Cases  in  which  sloughing  myomata  were  directly  the  cause  of  death  (Aut.  Nos.  69, 

1112,  2088,  2319) 4  cases. 

According  to  this  table,  in  S  cases  carcinoma  of  the  uterus  complicated  the 
myomata.  In  all  but  one  of  these  cas(>s  the  myomata  were  of  sufficient  size  to 
obscure  the  diagnosis.  In  one  case  the  myomata  had  become  sarcomatous. 
Thus,  out  of  148  autopsies,  in  (>  jx'r  cent,  the  myomata  were  associated  with 
malignant  changes  in  the  uterus. 

In  two  cases  the  ovaries  were  the  seat  of  primary  carcinoma.  In  one  instance 
primary  sarcoma  of  the  bladder  existed,  and  in  two  j)rimary  carcinoma  of  the 


AUTOPSY    FIXDIXGS.  429 

sigmoid  flexure  was  found.  Thus  in  14  out  of  148  cases  primary  malignant 
changes  were  present  either  in  the  uterus  or  in  one  or  other  of  the  pelvic  organs. 

In  4  cases  death  was  directly  attributable  to  the  uterine  hemorrhage,  and  as 
a  result  of  the  necrosis  and  sloughing  of  the  myoma.  Accordingly,  in  18  cases 
out  of  148,  death  was  primarily  due  to  changes  in  the  pelvic  oi'gans.  In  this 
connection  we  have  purposely  excluded  one  case  in  which  tuberculosis  of  the 
body  of  the  uterus  existed;  one  case  of  tuberculosis  of  the  tube,  and  those  cases 
in  which  the  myomata  by  pressure  caused  changes  in  the  ureters  and  kidneys. 

The  diagnosis  of  uncomplicated  uterine  myomata  is,  as  a  rule,  simple,  but 
when  other  pathologic  processes  develop  in  the  adnexa,  bladder,  or  rectum,  it 
becomes  impossible  for  the  operator  to  determine  the  exact  condition  until  he 
carefully  dissects  the  tumor  in  the  laboratory.  We  do  not  wish  to  make  any 
deduction  from  this  large  percentage  of  cases  in  which  changes  in  the  pelvic 
organs  were  the  primary  cause  of  death,  but  would  suggest  that  the  reader  care- 
fully review  the  data,  in  order  to  determine  in  what  percentage  of  cases  he  thinks 
he  would  have  been  likely  to  have  made  an  accurate  diagnosis,  and  then  decide 
for  himself  whether  it  is  wise  to  let  myomata  alone  or  to  remove  them. 


CHAPTiai  XXR'. 

THE  CAUSE  OF  UTERINE  MYOMATA. 

In  searching*  for  a  clue  as  to  the  origin  of  uterine  inyoniata  we  have 
approached  the  sul)je('t  from  three  main  avenues: 

1.  Heredity. 

2.  The  clinical  course  of  myomata. 

'A.  The  microscopic  appearance  of  very  early  myomata. 

Heredity, — In  the  accompanying  tabulation  are  embodied  the  findings  rela- 
tive to  the  family  history  in  1245  cases.  Naturally,  it  is  often  im])ossible  to 
determine  the  exact  nature  of  the  growths,  hence  it  has  been  thought  advisable 
to  give  all  the  available  data  concerning  tumors  of  every  kind  mentioned  as 
having  occurred  in  relatives. 

It  will  be  noted  that  in  11  cases  one  or  more  of  the  patient's  sisters  had  had 
uterine  myomata.     In  3  of  these,  two  of  the  patient's  sisters  had  had  myomata. 


Family  History  in  1245  Cases  of  Uterine  Myomata.* 

Grandmother:     Carcinoma,  9  cases  (.uterine  in  1  case). 

Mother:     Carcinoma,  20  cases  (uterine  in  6  cases). 

Sarcoma  of  jaw,  1  case. 

"Ovarian  tumors,"  2  cases. 

"Abdominal  tumors,"  10  cases  (1  myoma).     Death  was  due  to  the  tumor  in 

7  of  the  10  cases. 

Aunt:     Carcinoma,  21  cases. 

Abdominal  tumor,  5  cases. 

^  Uterus 2 

o-  ,  o      •  o  I   Breast   1 

bister:     Carcinoma.  8  cases:     i   ^^  , 

Stomach 1 

I-  "Cancer" 1 

"Tumor  of  \vo!iib,"  4  cases. 
"Abdominal  tumor,"  3  cases. 
Ovarian  tumor,  1  case 

'  2  sisters  (besides  patient) 3  cases 

Myomata,  1 1  cases:    \  1  sister 7      " 

I  1  half-si.ster 1  case 

11  cases 
Grandfatiier:        Carcinoma,      4  cases. 
Father:  "         24      "       (11  gastric). 

I'ncle:  "         11       " 

I5rother:  "  4      "       (2  gastric). 

*In  the  majority  of  the  cases  of  carcinoma  in  relatives  it  was  not  mentioned  whether  the 
patient  came  from  the  maternal  or  paternal  side. 

430 


THE  CAUSE  OF  UTERINE  MYOMATA 


431 


A  glance  at  the  foregoing  table  must  at  once  impress  the  reader  with  the  fact 
that  heredity  plays  little  or  no  role  in  the  development  of  uterine  myomata, 
although  in  a  few  cases  one  or  more  of  the  patient's  sisters  may  have  had  myo- 
mata of  the  uterus. 

The  Clinical  Course  of  Myomata. — From  the  table  on  p.  434  we  learn  that 
myomata  are  most  conmion  during  the  child-bearing  period,  and  from  p.  457  that 
of  1149  w^omen,  584  were  sterile.  Of  the  sterile  patients,  295  were  marrietl 
women  and  289  single.  The  impression  gained  by  us  after  a  critical  examina- 
tion of  the  histories  was  that  the  uterus  must  have  something  to  do,  and  that  if 
it  is  not  kept  relatively  l)usy  as  a  result  of  frequent  pregnancies,  it  may  tend  to 
show  its  activity  in  another  direction,  namely,  in  the  formation  of  myomata. 


Fig.  284. — A  Very  Early  Myoma.     (X  13.5  diam.) 
Gyn.   No.  33S.5.     Path.   No.  634.     The  myomatous  uterus  filled   the  pelvis.     Occupying  the  center  of  the 
field  is  an  oval-shaped  myoma.     The  muscle-fibers  in  the  myoma  as  yet  show  no  tendency  to  form  whorls.      M 
a  the  nuclei  of  the  myoma  gradually  merge  with  those  of  the  surrounding  muscle. 


On  the  oth(T  hand,  it  may  be  possible  that  the  unknown  factor  which  stimu- 
lates the  development  of  myomata  may  in  itself  tend  to  cause  the  sterility. 

The  Microscopic  Appearance  of  Very  Early  Myomata.  Where  large  iiiNoiiiat- 
ous  tumors  e.xist,  it  woulil  naturally  be  iin))().s.>^ible  lo  detenniiie  the  .source  of 
origin,  and  only  from  an  examination  of  the  niiiiule  niyoinala  can  we  hojie  to 
gain  any  definite  clue  as  to  their  mode  of  (le\-eloi)iiient . 

It  has  been  claimed  that  t  he  myomata  ])riniai'ily  dexclop  around  bloo(l-\-e.>^.seLs, 
and  we  have  carefully  examined  many  small  nodules  to  see  if  the  \-essels  realh' 
bore  any  causal  relation. 

In  Fig.  284  we  have  a  \-ery  earl\'  myoma,  ll  forms  an  o\al  nodule  and  i.s 
sharply  defined  from  the  surrounding  nmscle.  Its  nuclei  are  closely  packed 
together,  and   thus  the  myoma   ap])areMtly  stains  more  deeply   than   does  the 


432 


MYOMATA    OF   THK    ITHRUS. 


surrounding  muscle.  At  one  ]M)int  the  nodule  gradually  shades  off  into  the  sur- 
rounding tissue.  There  is  nothing  in  the  ])ieture  to  in  any  way  suggest  an  origin 
from  l)lood-vessel8. 

In  Fig.  2S5  we  have  a  myoma  slightly  larger  in  size.  The  muscle-fibers  in 
the  myomatous  area  show  a  marked  tendency  to  cui-l  up  in  bands  or  to  assume 
irregular  forms.     Otherwise  there  is  no  deviation  in  a])i)earance  from   the  sur- 


■'  •-.    '^-^Ci-X-      .■   -.VA..*^-:'-  ^■^'^'^•.  '  „•.>i^'W^■ 


-Vic  ■<*•  ■  ■•  •' 


\!^B^'^"°' 


Fig.  285. — .\n  E.\rly  Myom.\.     (X  35  diam.) 
Gyn.  No.  2699.     Path.  No.  246.     The  large  multinodular  myomatous  uteru.s  was  11  x  16  x  17  cm.     Occupy- 
ing the  greater  part  of  the  field  is  a  myoma,  recognized  by  the  wavy  arrangement  of  its  muscle-bundles.     Its  con- 
fines are  not  sharp,  but  can  be  definitely  made  out  at  a.     -•Vt  b  the  myomatous  tissue  blends  imperceptibly  with 
the  surrounding  muscle.     No  blood-vessels  are  to  be  seen  in  the  tumor. 


rounding  muscle.     In  this  myoma  also  there  is  not  the  .slightest  evidence  of  the 
tumor  having  developed  around  blood-vessels. 

Fig.  286  represents  an  early  myoma  from  a  ])regnaiit  uterus.  Here,  as  a 
result  of  the  pregnancy,  the  contrast  between  the  uterine  muscle  and  the  nodule 
comes  out  sharply.  The  nodule  is  approximately  spheiic.  and  composed  of  in- 
terlacing bundles  of  muscle-fibers.  It  has  no  blood-vessels  of  any  apprecial)le 
size.     At  some  points  it  gradually  blends  into  the  surrounding  muscle. 


THE  CAUSE  OF  UTERINE  MYOMATA. 


433 


In  none  of  the  myoniata  thus  far  studied  have  we  ever  seen  any  conclusive 
evidence  that  the  tumor  had  developed  around  blood-vessels. 


*    ';'  I    '.'     ■  *  ',>      ••   ."■■       '-"■-■       '\'  ■■        -  ■'v'.m':!-"^ 


&"'\''.'  ''^'^1 


lilip:; 


^ft'\\ 


..^"-^ 


^^■^ 


^i'.yycr?^ 


^■•'^;;;;   /■%>,;■■ 


.^^!r 


'  ^^K- 

-'•'■»»  ,^''' 


Fig.  286.— An  Eaki.v  Myom.\.      (X  tlO  diam  ) 

Gyn.  No.  2434.  Path.  No.  186.  In  this  case  Cesarean  section  fi)ll(iwc(l  l)y  iiysterectoiny  wa.*;  done  at  term  on 
account  of  a  large  pelvic  myoma. 

An  early  spheric  myoma  occupies  the  center  of  the  field.  It  consists  of  closely  packed  muscle-bundles  cut 
lengthwise  and  transver.sely.  It  is  sharply  defined  from  the  surrounding  muscle.  The  muscle-fibers  of  the  uterus 
(a)  are  swollen  as  a  result  of  the  pregnancy.  .At  b  tlie  myoma  is  separateil  from  tlie  muscle  by  a  definite  cleft, 
c  is  a  blood-vessel. 

We  still  k  n  o  w  p  r  a  c  t  i  c  a  1  I  y  not  h  i  ii  ^  ;i  s  t  o  I  h  v  o  r  i  g  i  ii 
of    uterine    in  \'  o  in  a  t  a  . 


28 


CHAPTER  XXY. 
THE  SYMPTOMS  ASSOCIATED  WITH  UTERINE  MYOMATA. 

In  this  fhajitci-  the  clinical  phenomena  (jccvn'i'ing  in  our  cases  have  been  care- 
fully analyzed,  hut  a  conii)lete  survey  of  the  literature  has  not  been  attempted. 

Age. — In  b'>()7  of  our  cases  we  have  definite  data  us  to  the  age  of  the  patient 
on  admission  to  the  hospital.  Of  course,  this  is  no  index  as  to  the  length  of  time 
the  tumors  had  existed. 

The  greater  number  had  been  de\'eloping  for  several  years,  l)ut  had  not 
been  detected  until  they  hatl  reached  goodly  proportions. 

From  the  table  it  will  be  noted  that  the  youngest  patient  (Gyn.  No.  9637)  was 
only  nineteen  years  of  age,  and  that  26  patients  were  under  twenty-five  years. 
The  oldest  j)atient  coming  for  operation  was  seventy-one.  In  our  experience  the 
great  pre])onderance  of  the  cases  came  to  oi)eration  l)etween  twenty-eight  and 
fifty-two  years  of  age. 

TABILATIOX    OF   AGES    OF    1307   CASES    OF    UTERINE    MYOMA    ON    ADMISSION 

TO  THE  HOSPITAL. 

Age  (in  Years)          Number  of  Cases.  Age  (in  Years)  Number  of  Cases. 

19 1         46 52 

20 3         47 34 

22 2         48 43 

23 6         49 33 

24 14  50 34 

25 12         51 20 

26 14  52 21 

27 15  53 10 

28 28         54 15 

29 28         55 4 

30 31         56 11 

31 21  57 4 

32 47         58 4 

33 46         59 8 

34 50  60 4 

35 61  61 3 

36 62  62 1 

37 47  63 1 

38 77         64 2 

39 65  65 2 

40 93  66 1 

41 49  67 1 

42 53  6S 0 

43 60  69 0 

44 50  70 1 

45 62  71 1 

Total 1307 

434 


THE    SYMPTOMS    ASSOCIATED    WITH    TTEIUXK    MYOMATA.  435 

In  Case  9637  the  patient,  a  mulatto,  was  only  nineteen  years  old.  She  had 
married  early,  had  had  one  child  and  one  miscarriage.  On  admission  to  the 
hospital  a  small  myoma,  2.5  cm.  in  diameter,  was  removed  from  the  right  uterine 
horn. 

In  Case  12216,  a  colored  woman,  twenty  years  old.  married,  entered  com- 
plaining of  abdominal  pain.  At  operation  a  multinodular  uterus,  12  x  12  cm., 
was  found,  and  a  subperitoneal  pedunculated  myoma,  8  x  8  x  10  cm.  This  was 
adherent  to  the  anterior  abdominal  wall  and  had  suppurated  (Fig.  104,  p.  136). 

In  Case  9652,  a  white  woman,  also  twenty  years  old,  had  a  myomatous 
uterus  about  11  cm.  in  diameter,  and  reaching  to  the  umljilicus.  In  Case  4382 
the  patient,  a  white  woman,  was  twenty  years  old.  Slie  had  married  early  and 
had  had  one  child.  For  one  month  there  had  been  profuse  uterine  hemorrhages. 
At  operation  a  submucous  myoma,  about  6x7  cm.,  was  removed. 

In  Gyn.  No.  2042  the  patient,  a  white  woman,  was  twenty-two  years  old. 
The  uterus  was  the  size  of  that  of  a  five  months'  pregnancy,  o\Wng  to  the  presence 
of  a  large  interstitial  nodule  in  the  posterior  wall.  This  was  removed,  and 
fourteen  years  later  the  patient  was  in  good  health  and  had  had  four  children 
since  the  operation. 

In  Case  11927  the  colored  patient  was  twenty-two  years  old.  She  had  had  a 
child  at  eighteen.  On  pelvic  examination  the  appendages  were  found  adherent, 
and  what  appeared  to  be  a  myomatous  mass,  7  cm.  in  diameter,  was  situated  to 
one  side  of  the  cervix.  As  the  patient  developed  measles  she  was  transferred  to 
the  medical  side  and  no  operation  was  performed. 

We  have  sketched  the  histories  of  those  cases  in  which  uterine  myomata  were 
recognized  at  an  early  age  in  order  that  the  reader  may  get  an  idea  as  to  the  size 
and  location  of  the  tumors.  It  \^^ll  be  noted  that  several  of  the  patients  were 
colored.  In  these  cases  there  is  always  an  element  of  uncertainty  as  to  the  correct 
age.  Such  a  mistake  is.  however,  less  likely  to  occur  in  the  young  colored  women 
than  in  the  old.  In  the  case  of  a  white  woman  therc^  is  less  room  for  doubting  the 
accuracy  of  the  patient's  statement  as  to  her  age 

From  the  findings  at  operation  it  is  evident  that  some  of  the  tumors  had 
existed  for  several  3^ears  prior  to  operation.  Accordingly,  in  a  few  of  tiie  cases 
the  patient's  uterus  must  have  been  the  seat  of  myomata  when  she  was  still  in 
her  teens. 

Duration  of  Uterine  Myomata  before  Operation.  It  is  \-ery  dillieult  to  (h-t er- 
mine with  any  degree  of  accuracy  just  how  long  it  has  taken  a  given  tumor  to 
develoj),  unless,  perchance,  at  a  pre\ious  abdominal  opei'ation  a  small  nodule  lias 
been  discovere(l  in  the  uterus,  but  foi'  some  I'eason  has  not  been  eiuicle.ated. 
Patients  fre(|uentiy  consult  the  surgeon  foi'  some  ill-ileliiied  abdominal  discom- 
fort, while  they  are  totally  unaware  that  the  pehis  is  filled  with  ;i  nodular  myo- 
matous uterus.  ( )n  the  other  hand,  if  a  patient  is  thin,  and  the  myoma  springs 
from  the  fundus,  it  is  often  felt  by  the  woman  herself.  In  some  ca.ses  the  tumor 
is  detected  an<l  then  cannot  be  found  for  some  months,  as  in  Case  3974.     This 


436  MYOMATA    OF   THP]    UTERUS. 

is  due  to  an  alteration  in  the  position  of  the  uterus.  When  once  the  patient  is 
under  the  physician's  care,  the  data  as  to  the  grachial  or  rapid  increase  in  the 
tumor's  dimensions  become  more  accurate. 

In  r.  H.  I.,  H..  Ai)ril  2S.  1<)()4,  we  have  a  good  example  of  the  gradual  increase 
in  size  of  the  myomata.  the  uterus  having  reached  half-way  to  the  uml)ilicus  at 
the  end  of  five  years. 

Many  patients  give  a  history  of  an  abdominal  tumor  of  several  years'  standing. 
Some  develop  gradually,  and  later  increase  rapidly  in  size;  others  grow  \\-ith  great 
raj)idity  when  first  noticed,  and  then  later  become  (piiescent. 

In  Case  ()94  the  tumor  had  a])])arently  entirely  filled  the  abdomen  by  the  end 
of  one  year;  in  Case  1628  the  growth  had  trebled  in  size  in  twelve  months. 

In  Case  1682  the  tiunor  had  a})parently  been  increasing  in  size  for  twenty- 
seven  months,  but  during  the  three  months  before  the  patient's  admission  ap- 
parently had  been  cjuiescent. 

In  Cases  1664,  2800,  3449,  the  increase  in  size  had  been  marked  during  the 
few  weeks  or  months  ])revi()us  to  o])eration. 

Many  of  the  i)atients  gave  a  history  indicating  that  the  uterine  enlargement 
had  commenced  from  one  to  ten  or  more  years  before  surgical  intervention  was 
sought,  and  in  a  few^  cases  the  tumor  had  existed  for  a  period  varying  from  ten 
to  thirty  or  more  years.  For  example,  in  Cases  2899  and  3426  the  tumor  had 
been  recognized  twelve  years;  in  Cases  3340,  3440,  and  3774,  fourteen  years; 
in  Cases  4(;i7  and  12864,  fifteen  years;  in  Cases  3281,  3394,  and  5946,  twenty 
years  before. 

Examples  of  long-standing  tumors  are  furnished  l)y  the  three  following  cases: 
In  Case  7460  the  tumor  had  been  recognized  twenty-two  years  before;  in  San. 
No.  1049,  for  over  thirty  years;  and  in  Case  10969,  for  thirty-six  years. 

San.  No.  1049  is  particularly  interesting,  as  in  this  case  an  exploratory  opera- 
tion had  been  performed  thirty  years  before.  The  surgeon  pronounced  the  case 
inoperable,  and  said  that  the  tumor  sat  right  down  flat  on  the  womb,  without  even 
a  particle  of  a  pedicle. 

When  the  tumor  reaches  very  large  proportions,  it  usually  remains  Cjuiescent 
unless  a  malignant  process  is  developing,  but  in  C.  H.  I.,  McA.,  the  tumor  had 
existed  for  over  twenty  years,  and  had  kept  on  increasing  in  size  until  it  had 
reached  a  weight  of  89  pounds. 

The  Abdominal  Contour,  The  general  abdominal  outlines,  when  uterine 
myomata  exist,  are  (le])endeiit  upon  several  factors: 

1.  The  location  of  the  tumor. 

2.  Its  size. 

3.  The  abuii(hiii(*e  or  sj)arsity  of  the  adij)ose  tissue.  A  tumor  may  com- 
pletely fill  the  pelvis  and  yet  not  project  into  the  general  cavity;  in  such  a  case 
the  contour  of  the  abdomen  is  little  altered. 

When  the  myoma  emerges  into  the  abdomen,  the  general  symmetric  lines  are 
changed.     The  shape  of  the  abdomen  will  depend  upon  the  size  and  location  of 


THE    SY:MPT0MS    associated    AVITH    UTKKIXK    MYOMATA. 


43^ 


the  tumor.  If  it  be  uninodiilar  and  globular,  there  may  be  a  dome-like  eleva- 
tion, as  in  rig.  2S7.  where  the  tumor  stands  out  .sharply  on  all  sides.  In  some 
cases,  for  example.  Case  7220,  the  abdomen  may  be  "obliciuely"  distended,  the 
tumor  occupying  the  entire  right  upper  half  and  the  lower  left  portion. 

AMien  the  abdomen  is  uniformly  distended  by  a  myomatous  tumor,  as  in 
Fig.  316  (p.  513),  and  the  ribs  are  pushed  far  outward,  the  appearance  strongly 
suggests  the  presence  of  an  ovarian  cyst. 

In  those  cases  in  which  j^arasitic  myomata  are  i)resent  and  ascitic  fluid  has 
been  pour(>d  out,  the  flanks  also  are  distended,  and  the  abdominal  contour  bears 
a  marked  resemblance  to  that  found  in  cases  of  fibroma  of  the  o^'ary  with  ascitic 
fluid  or  a  malignant  ovarian  tumor  with  free  abdominal  fluid. 


Fig.  287. — The  .•Vudominal  Contour  Caused  bv  a  Globular  Mvo.matous  Uterus. 
The  patient  is  stouter  than  in  Fig.  288.     The  tumor  produces  a  dome-like  elevation.     The  ascent  from  the 
symphysis  to  the  umbilicus  is  gradual;    the  descent  from  the  umbilicus  toward  the  xiphoid  more  abrupt.     There 
8  no  sagging  in  the  flank.     The  only  other  abdominal  tumor  likely  to  give  such  a  contour  would  be  an  ovarian 
cyst      In  the  latter  case  percussion  would,  in  most  instances,  yield  fluctuation,      (.\fter  Howard  .\.  Kelly.) 


In  some  cases  from  the  abdominal  contour  it  is  difficult  to  get  a  clear  idea  of 
the  condition,  but  in  others  a  glance  at  the  al)d()men  will  warrant  the  diagnosis 
of  a  myomatous  condition.  Such  an  abdomen  is  i)ictured  in  big.  2SS.  The 
growth  is  cleaiix'  niiiltiiioduiar,  has  "|)recipitoiis  edges,"  as  was  noted  in  (i\n. 
No.  90o7,  and  tliei-e  is  no  bulging  in  the  Hanks.  When  the  patient  is  \-ery  thin, 
as  in  this  case,  the  outlines  of  the  tumor  are  iiiucii  more  in  e\ideiice.  .\  thick 
mantle  of  adipose  tissue,  as  found  in  so  ni.any  cases,  naturally  obscures  the  sliarj) 
outlines  of  the  t  unior. 

Enlargement  of  the  Abdominal  Veins  Associated  with  Uterine  Myomata. — 
Dilated  x'eins  ;ire  irei|U('iiI  ly  noted  when  o\ai'iaii  cysts  or  malignant  o\arian 
tumors  exist.  If,  in  addilion  lo  the  o\aiian  growth,  ascites  is  found,  marked 
enlargement  of  the  veins  may  be  looked  for. 


438 


-MYOMATA    OF    THE    ITERUS. 


On  the  other  hand,  an  increase  in  the  size  of  the  abdominal  veins,  associated 
with  niyoniata.  is  rare.  Tlie  \'enous  dilatation,  when  ])resent,  is  due  chiefly  to 
an  interference  with  the  usual  avenues  of  circulation,  and  the  myoma,  as  a  rule, 
does  not  exert  much  pressure  on  the  abdominal  vessels.  In  a  fe\v  cases,  however, 
the  abdominal  veins  are  enlarged.  This  was  noted  in  Case  3113;  the  myomatous 
uterus  extended  above  the  umbilicus,  and  was  densely  adherent:  the  abdominal 
veins  were  dist  ended. 

The  Condition  of  the  Vagina  in  Cases  of  Uterine  Myomata. — Some  of  the  patho- 


FiG.  288. — The  Abdominal  Contodr  Caused  by  a  Multinodular  Myomatous  Uterus. 
(Jyn.  No.  1.3626.     The  patient  is  very  thin,  the  outlines  of  tlie  ribs  being  quite  prominent.     The  tumor  rises 
abruptly  from  the  abdomen,  is  markedly  lobulated.  aritl  there   is  no  sagging  in  the  flank.     In  this  case  the  clue 
furnished  by  the  abdominal  contour  alone  would  almost  warrant  a  definite  diagnosis  of  myoma. 


logic  conditions  found  are  dependent  Ujjon  the  myoinatous  condition,  liut  the 
majority,  as  will  be  noted,  must  i)e  considered  merely  coincidental. 

1.  Labial  cyst. 

2.  Shallow  vagina. 

3.  Bluish  mucosa. 

4.  \'aginal  cyst. 

o.   \'aginal  myoma. 

6.  Vaginal  phlcboliihs. 

7.  Ulceration  of  the  vagina. 

<S.   Induration  of  the  vaginal  vault. 

Labial  ("  y  s  t  . — Only  one  labial  cyst  has  come  under  our  ol)servation. 
In  Case  12681  the  uterus  was  the  seat  of  a  diffuse  adeiioiiiyonia.  Lying  in  the 
left  labial  fold,  and  nearly  on  a  level  with  the  clitoris,  was  a  cy.st  2  cm.  in  diam- 
eter. It  was  firmly  attached  to  the  skin,  but  was  freely  movable  on  the  under- 
lying structures.  Projecting  into  the  cyst  cavity  was  a  pedunculated  papilloma- 
tous mass  made  up  of  smaller  masses. 

Path.  No.  9473.     Microscopically,  the  papillomatous  masses  are  seen  to  be 


THE    SYMPTOMS    ASSOCIATED    WITH    ITKI^IXE    MYOMATA.  439 

covered  with  one  layer  of  eylindric  epithelium  which,  in  places,  tends  to  form 
glands.     There  is  nothing  suggestive  of  malignancy. 

Alterations  in  the  Size  and  Shape  of  the  \'  a  g  i  n  a  .  — If 
a  submucous  myoma  is  expelled,  the  vagina  must  neetls  dilate  sufficiently  to 
accommodate  the  tumor,  which  is  sometimes  large  enough  to  almost  completely 
fill  the  pelvis. 

A  large  intraligamentary  or  submucous  myoma  wedged  in  the  pelvis  may 
render  the  vagina  so  shallow  that  the  finger  cannot  be  carried  over  1  or  2  cm. 
straight  inward,  but  in  such  cases  it  can  be  introduced  backward  toward  Douglas' 
sac  or  forward  toward  the  l)ladder.  C.  H.  I.  No.  1205  affords  an  example  of 
complete  occlusion  of  the  upper  part  of  the  vagina.  This  patient  was  forty-two 
years  old  and  single.  The  myomatous  uterus  extended  as  high  as  the  umbilicus. 
The  vagina  was  greatly  narrowed,  and  half-way  up  there  was  complete  occlusion. 
With  the  finger  it  was  possible  to  separate  the  vaginal  walls  from  one  another, 
and  the  cervix  was  then  encountered. 

With  the  advent  of  old  age  the  vagina  naturally  contracts  considerably. 
In  Case  12681  the  contraction  was  very  marked.  This  patient,  although  the 
mother  of  eight  children,  had  a  vagina  that  would  not  admit  two  fingers. 

The  Bluish  Color  of  the  Vaginal  Mucosa.  — The  vaginal 
mucosa  usually  takes  on  a  bluish  tinge  in  pregnancy.  The  same  color  is  often 
presented  when  the  patient  is  under  the  influence  of  nitrous  oxid  gas,  or  if  the 
ether  or  chloroform  has  been  pushed  too  far.  In  the  unanesthetised  patient  this 
blueness  always  suggests  pregnancy. 

In  Case  7361  the  myomatous  uterus  reached  almost  to  the  umbilicus;  the 
outlet  was  markedly  relaxed,  and  there  was  slight  protrusion  of  the  anterior  and 
posterior  vaginal  walls.  The  mucosa  of  the  anterior  wall  was  bluish  in  color. 
When  pregnancy  exists,  the  bluish  tinge  is  found  over  all  parts  of  the  vaginal 
mucosa,  and  is  not  rniiile(l  \n  a  certain  area,  as  in  this  case. 

In  Case  (S0()8,  a  negress,  married,  aged  forty-one,  had  a  myomatous  uterus 
that  filled  the  ])elvis.  There  was  mark(>d  blueness  of  the  vaginal  mucosa.  In 
this  case  there  was  nlso  a  peb'ic  abscess  which  was  possibly  i-esponsible  foi-  the 
bluish  color,  although,  as  a  I'ule.  a  pel\"ic  abscess  does  not  cause  such  a  discolora- 
tion of  the  nuicosa. 

\  a  g  i  n  a  1  C  y  s  t  s  .  — The  association  of  \'aginal  cysts  with  utei-ine  inyo- 
mata  is  merely  a  coincidence,  in  Case  ')SW)  a  small  c>"st  was  detected  in  the 
posterior  vaginal  wall,  close  to  a  scar  in  the  sulcus. 

In  Case  ()S,")r)  a  cyst,  3  X  1 . 1  cm.,  was  found  in  the  left  lateral  wall,  just  within 
the  hymen. 

The  cyst  in  Case  SS  |  |  was  2.')  cm.  \  I..")  cm.,  oxoid  in  shape,  and  situated  in 
the  anterior  vaginal  wall  under  the  lu'ethra. 

All  these  cases  wei'e  rejxirted  in  detail  in  the  .Johns  Hopkins  Hospital  Bulletin 
for  1905.* 

*  Tliomas  S.  CulU'ii,  Wi-inal  Cy^ls,  .1.  II.  II.isp.  Hull..  UM).-,,  vnl.  \vi,  i\ '-'07. 


440  MVOMATA    OF    THE    UTERUS. 

A  \'  a  g  i  n  a  1  M  y  <>  in  a  .  — Myoniata  in  this  situation  are  rare,  and  we 
have  only  found  one  case  in  which  a  ^•a<;■inal  myoma  was  associated  with  uterine 
myoniata. 

In  Case  155S  the  uterus  contained  nunu'rous  myoniata,  and  wide-s})read  sar- 
comatous metastases  were  detected  in  the  mesenteric  and  peripancreatic  lymph- 
glands,  in  the  pei-itoneum,  omentum,  mesenteiy.  intestine,  stomach,  liver,  lungs, 
and  pleura*.     The  original  source  of  the  sarcoma  could  n(Jt  be  detected. 

Situated  in  th(>  j:)osterior  vaginal  wall,  and  loosely  embedded  in  the  tissue, 
was  a  myoma  2x4  cm.     This  was  shelled  out  with  ease. 

P  h  1  e  b  o  1  i  t  h  s  in  the  \'  a  g  i  n  a  1  Wall.  — In  Case  7600  the  uterus 
contained  several  small  myoniata.  Situated  in  the  left  vaginal  wall  were  several 
})hleboliths.  The  uterus  was  cureted  and  the  ])hleboliths  were  readil}^  dissected 
out.  The  pi-esence  of  "vein  stones"  in  the  vagina  is  excei)tional,  as  evidenced 
by  the  fact  that  we  detected  the  condition  only  once  in  between  1400  and  loOO 
cases. 

Ulceration  of  the  \'  a  g  i  n  a  .  — In  Case  12036  a  small  flat  myoma 
was  removed  from  the  |)osterior  surface  of  the  uterus  near  the  cervix.  Histologic 
examination  of  this  (Path.  No.  8579)  showed  that  it  was  a  typical  subperitoneal 
adenoinyoma.  Several  interstitial  myoniata  were  also  shelled  out.  A  right 
inguinal  hernia  was  then  repaired. 

Situated  in  the  posterior  \aginal  vault,  two  inches  from  the  outlet,  was  a 
granulating  area,  8  mm.  in  diameter.  As  the  vaginal  ulcer  was  not  excised,  but 
treated  locally,  we  cannot  be  sure  of  its  exact  nature.  The  Fallopian  tubes 
wei'e  normal. 

Induration  of  the  ^'  a  g  i  n  a  1  \'  a  u  1  t  Associated  with 
U  t  e  r  i  n  e  .M  }•  o  m  a  t  a  .  — This  condition  can  usually  be  easily  differentiated 
from  myoniata  projecting  into  the  vagina.  \Miei-e  myoniata  encroach  on  the 
vagina,  the  mucosa  covering  them  is  perfectly  smooth,  stretched,  and  gives  the 
sensation  of  being  relatively  thin.  Where  there  is  marked  induration,  the 
sharply  curved  outlines  ai'e  lost,  and  the  vault  has  a  dense,  board-like  feel; 
and  where  abscess  foi'ination  is  fai'  advanced,  there  may  l)e  areas  of  softening 
or  fluctuation  scattered  throughout  the  board-like  tissue.  The  differences  are 
analogous  to  the  contrast  between  the  sharply  (uit lined  ]iicture  {)resente<l  by  a 
fibroma  of  the  skin  and  the  hard.  i)i-awny  .  and  I'ather  indistinct  ccntcurof  aboil. 

A  reference  to  Chapter  X\'I1I  (p.  337)  will  show  that  inflanunation  of  the 
tubes  is  a  very  common  accompaniment  of  uterine  myoniata,  and  that  the  in- 
flammation not  infrequently  goes  on  to  abscess  formation. 

The  Condition  of  the  Cervix  as  Detected  by  Digital  Examination. 

1.  Normal  cervix.      {<i)  In  the  usual  position.      (/■)  Carried  up. 

2.  Cervix  almost  obliterate(l  or  llu-^h  with  the  vaginal  \ault. 

3.  Cervix  jammed  down  on  the  perineum  or  up  behind  the  symj)hysis. 

4.  Edema. 


THE    SYMPTOMS    ASSOCIATf]D    WITH    ITKRIXE    MVOMATA.  441 

5.  Elongation  and  hypertroj)hy  of  the  vaginal  portion  of  the  cervix. 

6.  Dilatation  of  the  cervix  caused  by  suljnuicous  niyomata. 

7.  Carcinoma  of  the  cervix. 

Normal  Cervix.  — The  shape  and  position  of  the  cer\ix  will  to  a  great 
extent  depentl  on  the  size  and  situation  of  the  myomata.  If  the  myoma  has 
developed  in  such  a  manner  that  the  uterus  is  not  encroached  upon,  the  cervix 
will  usually  be  of  the  normal  size  and  in  its  proper  ])lace;  but  when  the  uterus  is 
uniformly  enlarged,  it  gradually  rises  into  the  abdomen  and  carries  the  cervix  up 
with  it. 

Again,  when  many  myomata  are  growing  at  the  same  time,  the  uterus  is 
occasionally  found  completely  surrounded  by  the  tumor.  In  such  cases  also  it 
may  be  carried  high  into  the  abdomen,  and  the  cervix  can  with  difficulty  be 
palpated  by  the  finger  in  the  vagina. 

Cervix  Almost  Obliterate  d  .  — When  the  myomatous  develo])- 
ment  has  been  particularly  pronounced  in  the  cervical  region,  the  cervix  may  be 
encroached  upon  to  such  an  extent  that  it  is  almost  completely  unfolded,  the 
edges  merging  almost  imperceptibly  into  the  vaginal  walls  (Fig.  40,  \).  57). 

In  Case  6198  the  cervix  was  flush  with  the  vaginal  vault.  In  Case  3498  it 
was  almost  obliterated,  antl  in  Case  8106  represented  by  a  small  pit.  The  en- 
croachment of  the  myoma  on  the  cervix  in  Case  4370  was  so  pronounced  that  the 
"cervix  shaded  off  into  a  large  abdominal  mass  wedged  tightly  in  the  i)elvis.'' 

Cervix  Jammed  Down  on  the  P  e  r  i  n  e  u  m  o  r  up  Be- 
hind the  S  y  m  j)  h  y  s  i  s  .  — When,  as  a  result  of  adhesions  or  of  subperi- 
toneal develo])ment,  the  u])ward  course  of  the  myomatous  growth  is  iiitcifenMl 
with,  the  tmnor  pushes  its  way  downward.  In  such  cases  the  vagina  may  be 
greatly  shortened;  the  cervix  may  ])ress  down  upon  the  perineum  or  be  carried 
upward  and  forward,  and  be  jannned  against  the  symphysis.  In  such  cases  it 
may  l)e  difficult  to  reach  with  the  examining  fing(>r,  and  can  be  recognizc^d  as  a 
slightly  altered  cervix,  a  hnlf-moon-sha))e(l  slit  (as  in  Case  oUl),  or  as  a  mere 
button  (Case  4731). 

1"]  d  e  m  a  of  the  Cervical  Lips.  In  Case  1(110  the  ulciiis  was 
jmrtially  inverted  as  a  result  of  the  li'actioii  of  a  submucous  myoma,  and  the 
cervical  lips  wer(^  edematous. 

K  1  o  n  g  a  t  i  o  n  o  f  t  h  e  \'  a  g  i  n  a  1  Portion  of  the  ( "  c  i-  \  i  x  .  — 
In  four  cases  we  have  I'ccoi'ds  of  inai'kcd  liypciirophy  of  the  ccrNix  associated  w  iih 
uterine  myomata.  In  Case  r)<S4.">  there  was  |)rolapsus,  clongalion  ol'  llic  cci-\i\. 
and  a  small  adhei-ent  myomatous  utei'us. 

In  Case  444  I  the  adherent  myomatous  uterus  measured  (1  \ '.)  \  II  cm.  Tlieiu' 
was  ))rolaj)sus  of  the  uterus  and  liypei'ti'opliic  eloiigal  ion  of  the  cer\i\.  with  slight 
cervical  ulceration. 

In  Case  7441  the))aiieid,  although  mai'ried  eight  years,  iiad  ne\-ei-  been  pi'eg- 
nant.  Th(>  vaginal  portion  of  the  cei'X'ix  was  7..")  cui.  in  leni;th,  and  piotruded 
3.5  cm.  fi-om  the  \-ul\'a.     The  uteiais  containeil  a  ni\-onia  about  7  cm.  in  di.a meter. 


442 


MYO.MATA    OF   THE    UTERUS. 


The  most  reniarkal)le  liyi)('rtroj)hy  of  the  cervix  we  have  ever  encountered 
was  in  Case  6240.  There  was  marked  prolapsus  and  enlargement  of  the  cervix; 
the  body  of  tlie  uterus  was  correspondingly  enlarged  as  a  result  of  a  (Hffuse  adeno- 


mvouia. 


It  will  he  seen  that  in  each  of  these  cases  there  was  j)r()la))sus  of  the  uterus, 
and  further  that  the  myomatous  condition  was  apparently  in  no  way  responsible 
for  the  hypertrophy  of  the  cervix. 

Dilatation  of  the  cervix  due  to  submucous  myomata  is  described  on  p.  61; 

carcinoma  of  the  cervix  associated  with   uterine 
myomata  on  p.  202. 

A  Thrill  Felt  on  Vaginal  Examination. — In  C. 
II.  I.  \V.  (Path.  Xo.  6421)  a  large  globular  myo- 
matous uterus  was  present.  A  definite  thrill  was 
felt  along  the  course  of  the  left  uterine  artery. 
The  same  sensation  was  transmitted  to  the  finger 
each  time  a  vaginal  examination  was  made. 

Elongation  of  the  Supravaginal  Portion  of  the 
Cervix  Associated  with  Uterine  Myomata. — In  Cape 
12590  the  uterus  was  considerably  thickened,  owing 
to  the  presence  of  a  diffuse  adenomyoma.  The 
cervix  was  lengthened  to  such  an  extent  that  a 
total  hysterectomy  would  have  been  exceedingly 
ditlicult.  As  .soon  as  malignancy  was  excluded, 
the  uterus  was  amputated  through  the  cervix. 

The  uterus  in  Case  11944  was  several  times  the 
natural  size,  being  15  cm.  in  diameter.  The  cer- 
vix, which  was  10  cm.  long,  was  at  first  mi.staken 
for  a  senile  uterus. 

Excessive  elongation  of  the  cervix  is  illustrated 
in  Fig.  2S9.  Here  the  fundus  is  ()ccui)ied  by  an 
irregular  globular  myomatous  tumor,  while  the 
cervix  is  drawn  out  until  it  is  as  long  as  a  normal 
uterus. 

Character  of  the  Uterine  Discharge. — As  a  pre- 
liminary to  the  study  of  the  character  of  the  men- 
strual  flow  and    the   intermenstrual   discharge,   a 
brief  ref(M"ence  may  l)e  made  to  Cha])ter  I,  which 
deals  with  the  general  distribution  of  uterine  myomata,  and  to  Chapter  XVH,  in 
which  the  condition  of  the  uterine  nuico.sa  in  myoma  cases  is  dealt  with  in  detail. 
Uterine  discharges  are  naturally  divisible  into  two  main  groups: 
1.  Menstrual.     2.   Intermenstrual. 


Fig.   289. — Marked      Eloxgatio.n 
OF    THE    Supravaginal    Por- 
tion OF  THE  Cervix. 
.\ut.  No.  1689.     The  fundus  of 
the  uterus  is  Rreatly  enlarged   and 
rather  irregular  in  outline,  owing  to 
the  presence  of  myomata.     Passing 
off    from    the    lower    and    anterior 
surface  of  the  uterus  are  the  round 
ligaments.     The    cervix    is    greatly 
lengthened  out,  extending  from  the 
external  os  to   a,   where  it  is  much 
attenuated. 

It  is  in  just  such  a  case  as  this 
that  torsion  of  the  cervix  might  be 
expected. 


*  This  case  is  reported  in  detail  in  "Adenomyoma  of  tlie  Uterus."  and  tl 
trated  in  Fig.  56  (p.  201)  of  that  publication. 


condition  is  illus- 


THE    SYMPTOMS    ASSOCIATED    WITH    I'TEKIXE    MYOMATA.  443 

M  e  n  s  t  r  u  a  t  i  o  11  .  — In  the  vast  majority  of  cases  the  menstrual  function 
is  in  no  way  influenced  ])y  the  ]:)resence  of  myomata,  and  the  flow  may  even  be 
diminished.  In  carefully  tabulating  the  cases  in  which  the  menstrual  flow  was 
excessive,  and  often  associated  with  an  intermenstrual  discharge,  we  have  been 
struck  l:)y  the  great  regularity  with  which  the  myomata  were  of  the  submucous 
variety.  In  the  more  pronounced  cases  these  submucous  tumors  were  recog- 
nized before  operation;  in  other  cases  only  after  the  uterus  had  been  oj^ened. 

After  carefully  weighing  the  clinical  and  pathologic  findings,  we  have  not  the 
slightest  hesitancy  in  saying  that  in  nearly  every  ease  the  uterine  bleeding  is  due 
to  the  encroachment  of  one  or  more  myomata  on  the  uterine  mucosa.  The 
mucosa  is  ])ut  on  tension,  there  is  an  increased  blood-pressure,  and  the  large  veins, 
which  naturally  once  a  month  pour  out  their  quota  of  menstrual  l)lood,  are  now 
Hkely  to  yield  a  moderate  cjuantity  between  periods  and  an  excessive  amount 
during  the  period.  No  matter  how  large  the  myomatous  uterus,  providetl  the 
contour  of  the  uterine  cavity  is  unaltered  and  the  mucosa  in  no  way  impinged  upon 
by  the  myomata,  there  will  rarely  be  any  disturbance  in  the  menstrual  function. 

If  it  is  possible  to  exclude  the  presence  of  uterine  polyjH,  which  frccpiently 
cause  hemorrhage,  of  diffuse  adenomyomata,  which  are  associated  with  profuse 
menstruation  but  little  or  no  intermenstrual  bleeding,  ami  adenocarcinoma,* 
which  occasionall}^  accompanies  uterine  myomata,  one  can  sa}'  with  almost  ab- 
solute certainty  that  the  uterine  hemorrhage  which  occurs  in  association  with  the 
myomatous  uterus  is  due  to  a  tumor  of  the  submucous  variety. 

Menstrual  H  i  s  t  o  r  y  .  — In  these  cases  the  patient  usually  gi\-es  the 
history  of  a  gradual  increase  in  the  loss  of  blood  at  the  i)erio(ls.  In  some,  menor- 
rhagia  has  been  noticed  for  only  a  few  months,  and  in  others  for  ten  years  or  more. 
The  length  of  time  usually  varies  inversely  with  the  rapidity  with  which  the 
myoma  has  become  submucous  and  with  whicli  the  uterus  has  exjx'lhMl  it  into 
the  vagina.  The  increase  in  amount  may  be  so  unexpected  or  sudden  that  tlic 
flow  really  amounts  to  a  hemorrhage,  as  ha])])ened  in  Case  27(M).V.  It  may  be 
continuous  or  come  in  gushes,  as  was  noted  in  Case  H154.  In  some  instances  it 
is  so  excessive  and  persistent  that  the  patient  has  to  remain  in  Ix'd  to  prevent 
flooding,  and  even  this  precaution  may  not  stay  the  bleeding.  For  example, 
in  Case  11944  the  hemorrhage  was  so  excessive  that  it  became  necessary  to  j)a('k 
the  uterine  cavity.     Any  increase  in  blood  j)ressure  may  bi'ing  on  a  hcinoi-i'hage. 

Where  bleeding  was  free,  little  pain  was  e\|)eiienced,  but  if  the  blood  came 
away  in  clots,  or  if  it  was  teinjioi-arily  dainine(l  back,  the  disconifoii  was  usually 
severe. 

When  the  myomata  do  not  imj)inge  on  the  utei'ine  nnicosa.  the  menopause 
will  usually  occur  at  the  normal  time,  but  if  at  a  later  date  the  myomata  be- 
come submucous,  bleeding  is  likely  to  occui". 

*  Of  course,  in  such  a  case  as  No.  1()91,  in  wliidi  tlie  submucous  myoma  was  associated  willi 
adenocarcinoma  of  the  body,  a  satisfactory  deduction  could  not  \)c  drawn.  This  case  is  reporte  1 
in  detail  on  p.  288, 


444  MVO.MATA    OK    THK    UTERUS. 

lute  r  111  e  11  s  t  r  u  a  1  H  1  e  c  d  i  ii  g  .  — In  some  cases  the  j)eno(ls  are  so 
long  that  tlie  intermenstrual  interval  is  very  short  or  almost  wanting.  In  other 
cases  there  is  a  continuous  slight  hemorrhage,  or  oozing  of  blood,  and  the  periods 
are  recognized  as  exacerl)ations  of  the  flow.  In  some  of  the  cases  this  continuous 
flow  had  cxistiMl  for  a  few  months,  in  othcM-s  it  had  been  present  for  three  or  four 
years. 

A\'hen  the  intermenstrual  i)eri()d  is  of  some  (hn'ation,  there  is  liable  to  be  a 
leukorrheal  discharge.  This  is  whitish  or  yellowish  in  color,  and  is  often  l)lood- 
tinged  just  before  and  after  the  jjeriod.  In  some  cases  the  discharge  is  watery 
and  may  hv  irritating. 

If  the  submucous  myoma  is  undergoing  disintegration,  the  discharge  tends  to 
be  more  profuse,  and  at  times  is  fetid.  This  watery  discharge  associated  with 
some  of  the  submucous  myomata  is  almost  nauseating,  and  cannot  be  distin- 
guished from  that  accompanying  a  far-advancc\l  carcinoma  of  the  cervi.x. 

Pruritus  Vulvae. — ^This  distressing  symptom  is  rarely  caused  by  uterine 
myomata,  even  those  of  the  sloughing  submucous  variety.  In  only  one  of  our 
cases  was  it  in  any  way  j^ronounced.  In  Case  2606  the  patient  entered  the 
hos])ital  com))lainiiig  chieHy  of  pruritus  vulva\  The  external  genitals  showed 
excoi'iatioiis  and  a  few  raw  areas.  The  uterus  contained  a  myoma,  11  cm.  in 
diameter.  A  hysterectomy  was  performed,  and  the  patient  was  at  once  com- 
pletely I'elieved  of  the  pruritus.  The  itching  in  this  case  was  undoubtedh'  due 
to  the  irritating  discharge.  The  myoma  was  of  the  submucous  variety,  but  on 
histologic  examination  the  mucosa  covering  it.  aside  from  some  thinning  out, 
appeared  perfectl}'  noi'inal. 

Bleeding  into  the  Abdominal  Cavity  after  Bimanual  Examination  of  Sub- 
peritoneal Pedunculated  Myomata. — The  surgeon  is  often  impresseil  by  the  ease 
with  which  a  subperitoneal  ])edunculated  myoma  can  be  torn  away  from  the 
uterus.  When  severance  takes  place,  there  is  natvu-ally  free  hemorrhage. 
This  tendency  for  the  myoma  to  tear  away  should  always  be  borne  in  mind 
when  making  a  bimanual  examination. 

Some  years  ago  one  of  us  (L'uUen)  was  demonstrating  a  case  of  multinodular 
uterus,  and  several  students  examined  the  patient.  The  abdomen  was  o])ened 
about  ten  minutes  later  for  removal  of  the  uterus.  One  of  the  examining  grouj) 
had  evidently  used  too  much  forc(\  as  a  subperitoneal  nodule,  about  10  cm.  in 
diameter,  had  been  partially  torn  away  from  the  uterus,  and  even  in  a  few 
minutes  se\-ei'al  liuiidi-e(l  cubic  centimeters  of  blood  had  escaped  into  the 
abdomen.  In  this  case  the  outcome  was  perfectly  satisfactory,  but  if  this 
examinaticjii  had  been  made  in  a  j)rivate  Ikjusc  and  not  just  prior  to  ojx'ra- 
tion,  the  hemorrhage  might  have  proved  fatal. 

In  Chapter  II  it  has  been  pointed  out  that,  when  i)arasitic  myomata  exist, 
large  free  vessels  plunge  into  the  tumor.  In  such  cases  also  the  bimanual  ex- 
amination must  be  made  most  gently. 

Mobility. — In  estimating  the  mobility  of  the  tumor  in  any  given  case  the 


THE    SYMPTOMS    ASSOCIATED    WITH    I'TERIXE    MYOMATA.  445 

variety  of  myoma  with  wliich  we  are  dealing  must  naturally  be  taken  into  con- 
sideration. If  the  myoma  is  subnmcous,  the  degree  of  mobility  will  depend 
upon  that  of  the  uterus.  When  the  myoma  is  large,  the  round  ligaments  are 
pulled  taut,  and  only  a  limited  excursus  of  the  uterus  is  possible.  If  the  tumor 
is  interstitial  and  not  very  large,  less  traction  will  be  exerted  on  the  ligaments 
and  the  uterus  will  be  more  movable.  Subperitoneal  nodules,  if  pedunculated, 
can  often  be  pushed  from  one  side  of  the  abdomen  to  the  other,  and  in  thin 
individuals  can  sometimes  be  Hfted  up  in  the  hands. 

When  the  patient  has  had  children,  the  broad  ligaments  and  the  vagina  are 
naturally  more  lax,  and  the  degree  of  mobility  is  consequently  greater  than  in  the 
nullipara. 

The  following  cases  exemplify  the  marked  degree  of  mobility  that  may  exist 
in  some  instances.  In  Case  2005,  in  which  the  multinodular  uterus  extended  to 
the  umbilicus,  the  patient  noticed  that  the  tumor  changed  its  position  with 
any  alteration  of  her  own.  Case  9953  was  that  of  a  very  intelligent  physician, 
thirty-tw^o  years  of  age.  The  uterus  was  hard  and  nodular,  and  on  pelvic  ex- 
amination was  found  to  extend  half-way  to  the  umbilicus.  She  noticed  that 
the  tumor  moved  about  the  abdomen;  in  the  morning  it  would  be  well  up  to- 
ward the  umbilicus,  but  after  she  had  walked  about  for  some  time  it  settled  more 
into  the  pelvis.  A  myomectomy  was  performed,  and  the  patient,  writing  from 
India  five  years  later,  reported  herself  as  feeling  perfectly  well.  In  Case  10555, 
a  subperitoneal  tumor,  10  cm.  in  diameter,  sprang  from  the  posterior  surface  of 
the  utenis.  The  enlarged  uterus  "could  be  displaced  to  any  part  of  the  ab- 
domen"; in  fact,  so  mobile  was  it  that  it  was  thought  to  be  an  ovarian 
cyst. 

WTien  pelvic  adhesions  exist,  the  mobility  of  the  uterus  is  usually  much 
restricted. 

A  bimanual  examination  with  the  patient  anesthetized  often  proves  of  the 
greatest  assistance  to  the  surgeon.  He  at  once  learns  the  relative  degree  of 
mobility  of  the  lumoi',  and  can  dctcrniinc  with  sonic  accuracy  whether  the 
operation  will  be  easy  or  diflicult.  The  discovery  of  a  lai'ge  cervical  myoma 
that  has  unfolded  the  cervical  canal,  or  a  jx'lvis  packed  with  myomata  and 
a  marked  narrowing  of  the  vagina,  usually  indicates  that  einicleation  will  prove 
difficult.  On  the  other  hand,  when,  with  the  finger  in  the  vagina  and  the  hand 
over  the  abdomen,  one  is  able  to  lift  th(  entire  mass  well  up  into  the  abdomen, 
the  pelvic  portion  of  the  operation,  at  least,  is  likely  to  be  easy.  Occasionally, 
however,  even  with  dense  j)el\'ic  adhesions,  the  pel\ic  cdntents  can  be  nio\cd 
upwai'd  and  downward  en  masse. 

Constipation. — Constipation  is  frc(|ucnlly  associatccl  with  uterine  nivdniata. 
Many  of  the  patients  give  a  history  of  constipation  daling  fi'oni  a  few  nionlhs 
to  two  or  three  years  prior  to  tlieii'  a<lniission  to  the  hospital,  although  bctorc 
that  time  the  bowels  had  been  regulai'.  Other  patients  have  been  constijjated 
for  many  years,  but  during  the  last  six  months  or  a  yeai'  the  constipation  has 


446  MYOMATA    OF   THE    UTERUS. 

l)ecn  more  obstinate.  In  Case  6381  the  patient  at  times  went  for  two  weeks 
without  a  movement. 

In  many  instances  the  myomata  are  the  direct  cause  of  the  constipation. 
Patients  freciuently  c()mi)lain  of  severe  pressure  in  the  rectum  (Case  4959),  or 
that  the  constipation  is  due  to  something  coming  down  when  they  go  to  stool. 

Myomata  of  moderate  size  that  accurately  fill  the  pelvis  often  exert  a  very 
firm  pressure  on  the  rectum,  and  more  frequently  cause  constipation  than  do  the 
larger  tumors,  which,  on  account  of  their  size,  are  carried  uj)  out  of  the  pelvis. 

When  the  tumors  not  only  fill  the  pelvis,  but  are  also  firmly  fixed  by  ad- 
hesions, the  tendency  to  constipation  is  naturally  increased. 

With  the  shifting  of  the  tumor  in  the  pelvis  or  its  outgrowth  from  the  confines 
of  the  pelvis  and  extension  to  the  general  abdominal  cavity  the  existing  con- 
stipation may  cease.  In  Case  6441  the  pati(»nt  had  been  constipated  until 
four  months  before  her  admission.  This  change  is  to  be  explained  by  the  fact 
that  the  tumor  altered  its  relations,  which  allowed  the  bowels  again  to  become 
regular. 

In  some  cases  constipation  is  evidently  due  to  ])artial  intestinal  obstruction. 
In  Case  12811  the  bowels  were  j^rone  to  be  constipated,  "especially  when  the 
tumor  swelled,"  the  swelling  evidently  indicating  distention  of  the  bowel  due 
to  its  inability  to  empty  itself. 

Hemorrhoids, — Constipation  is  frequently  associated  with  uterine  myomata, 
the  sluggish  bowel  action  in  large  measure  being  due  to  pressure  of  the  tumor 
upon  the  rectum.  This  obstructive  condition  naturally  retards  the  return 
flow  in  the  rectal  veins,  and  might  favor  the  development  of  hemorrhoids. 
Nevertheless,  only  rarely  are  these  associated  with  myomata. 

^^'h(■Il  a  cervical  myoma  is  fixed  in  the  pelvis,  as  in  Case  11243,  hemorrhoids 
are  almost  certain  to  develop.  If  the  myoma  that  has  previously  caused  dila- 
tation of  the  rectal  veins  alters  its  position,  the  hemorrhoids  may  disappear,  as 
was  noted  in  Case  6376,  in  which  they  vanished  one  year  before  the  patient's 
admission  to  the  hospital. 

If  hemorrhoids  are  present  at  the  time  a  hysterectomy  is  performed,  but  are 
of  a  relatively  mild  grade,  nature  will  usually  take  care  of  them,  and  they  will 
disappear  spontaneously  after  the  obstruction  is  removed.  If,  however,  the}'  are 
of  an  aggravated  type,  removal  at  once  is  the  wiser  procedure,  {provided  the 
patient  is  in  good  condition  after  the  abdominal  operation. 

Painful  Defecation. — This  is  usually  associated  with  constipation,  and  ma}'  be 
intermittent  or  accoinpaii}'  each  stool.  When  hemon-hoids  exist,  the  cause 
of  the  pain  is  clear.  In  most  cases  it  seems  to  be  due  to  the  pressure  of  the 
tumor  on  the  rectum,  ami  any  pelvic  adhesions  that  may  be  present  are  apt 
to  aggravate  the  discomfort.  We  have  noted  a  certain  constancy  with  which 
frequent  and  painful  iiiicturition  and  painful  defecation  occur  together. 

Pruritus  Ani. — The  occurrence  of  this  sym})tom  with  uterine  myomata 
appears  to  be  most  unusual,  as  only  one  patient  in  our  entire  series  conq)lained 


THE  sy:mptoms  associated  with  UTERIXK  MYOMATA.  447 

of  it.  In  Case  8462  the  patient,  aged  forty-one,  for  two  years  prior  to  admission 
had  noticed  a  persistent  and  annoying  itching  in  and  around  the  anal  orifice. 
So  severe  was  it  that  her  hands  were  tied  each  night  to  prevent  her  scratching 
the  parts. 

On  visual  examination  nothing  could  be  detected.  Pelvic  examination 
revealed  a  multinodular  myomatous  uterus  (Fig.  318,  p.  516).  Thirteen  myomata 
were  enucleated.  The  pruritus  ceased  innnediately  after  o[)eration  and  never 
returned.  Over  six  and  one-half  years  have  now  elapsed  since  the  operation. 
In  this  case  the  pressure  of  the  enlarged  uterus  was  evidently  responsible  for 
the  pruritus. 

Nausea  and  Vomiting. — As  is  well  known,  in  the  early  months  of  })regnancy, 
when  the  uterus  is  undergoing  a  gradual  dilatation,  nausea  and  vomiting  are 
not  infrt>ciuent.  and  since  the  rapid  development  of  myomata  sometimes  greatly 
alters  the  shape  and  size  of  the  uterus,  a  certain  amount  of  reflex  nausea 
and  vomiting  might  be  expected.  In  only  two  of  our  cases,  however,  was  there 
a  history  of  nausea. 

In  Case  4203  the  uterus  was  about  the  size  of  that  of  a  three  months'  preg- 
nancy and  free  from  adhesions.  The  patient  suffered  from  nausea  and  back- 
ache, more  pronounced  at  the  menstrual  period.  In  Case  1787  the  uterus  filled 
the  lower  abdomen  and  the  patient  complained  of  irregular  attacks  of  nausea 
and  vomiting. 

On  the  whole,  then,  myomata  have  little  or  no  tendency  to  cause  nausea 
or  vomiting.  Of  course,  when  the  small  bowel  becomes  densely  adherent  to  the 
enlarged  uterus,  kinking  may  follow  and  vomiting  may  occur  as  a  result  of 
intestinal  obstruction. 

Partial  Intestinal  Obstruction  Prior  to  Operation. — In  view  of  the  nunuuous 
cases  in  which  intestinal  adhesions  are  present  (see  p.  633)  it  is  hardly  a  matter 
of  surprise  to  find  that  in  a  certain  proportion  partial  intestinal  ()l)structi()n  has 
existed  i)rior  to  operation. 

In  Case  6521,  a  negress,  aged  forty-three,  had  had  definite  signs  of  j)artial 
obstruction  before  coming  to  the  hospital.  At  operation  the  adherent  myomatous 
uterus,  an  ovarian  cyst,  and  an  adherent  appendix  were  removed.  The  intestines 
were  greatly  distended  and  everywhere  adherent.  The  patient  was  exceetlingly 
weak  before  operation.  The  intestinal  obstruction  increased  after  opei'ation 
and  she  died  on  the  eight li  day. 

In  Case  8()1)S  a  white  woman,  aged  thirty-eight,  had  noticed  a  ccrlain  degree 
of  obstruction  of  the  bowels  for  two  years.  At  opei-ation  scNcral  niyouiata  were 
removed.  There  were  no  intestinal  adhesions.  Tiu'  obstruction  had  probal)ly 
been  due  to  pressure  of  the  myomatous  uterus  on  the  bowel. 

In  Case  12216,  a  negr(>ss,  aged  twenty,  four  inonlhs  before  admission  hail 
partial  obstruction.  The  abdomen  was  swollen  for  thi'ce  or  four  weeks.  Sjie 
had  some  vomiting,  and  experienced  dilliculty  in  se(an-ing  a  movement.  \\ 
operation  a  loop  of  small  bowel  was  found  adherent  to  the  anterior  abdominal 


448  MYO.MATA    OF   THE    UTERUS, 

wall  at  the  jjoint  at  which  a  suppurating  suhjK'ritoiical  inyoina  had  become 
adherent.  The  patient  died  of  intestinal  obstruction  a  few  days  after  operation. 
This  case  is  re]X)rted  in  detail  on  p.  135. 

In  Case  I'iOOO  tiie  woman  entered  the  hospital  as  an  emei-gency  patient  on 
account  of  acute  intestinal  obstruction.  It  was  thought  that  the  pressui'e  of  the 
myomatous  uterus,  which  was  firmly  wedged  in  the  pelvis,  had  caused  the  ob- 
struction. At  operation  the  narrowing  of  the  bowel  was  found  to  be  due  to  a 
coexisting  carcinoma  of  the  sigmoid  (Fig.  274,  p.  393). 

Pain. — In  the  majority  of  cases  of  uterine  myomata  little  (jr  no  jmin  is  ex- 
perienced by  the  patient. 

When  the  tumor  is  adherent,  the  adhesions  naturally  often  give  rise  to  a  good 
deal  of  distress,  i)ut  at  the  i)r(>sent  time  we  are  chiefly  interested  in  those  cases 
in  which  the  discomfoi't  is  due  mainly  to  the  tumor  itself. 

Our  histories  go  to  show  that  tumors  of  moderate  size  cause  the  most  pain. 
Sometimes  very  small  myomata  located  in  the  pelvis  give  rise  to  a  good  deal  of 
discomfort,  but  very  large  ones  are  forced  into  the  general  abdominal  cavity 
and  cause  relatively  little  i)ain. 

A  patient  will  often  consult  her  physician  without  any  idea  that  she  has  a 
tumor,  although  complaining  of  a  heavy  weight  in  the  lower  alxlomen,  as  in 
Case  4526;  or  she  may  be  suffering  from  a  severe  bearing-down  sensation  in 
the  lower  abdomen  after  exertion.  In  Case  337  the  patient  experienced  much 
abdominal  pain  on  stooj^ing  over.  Other  patients  suffer  from  a  constant  sore- 
ness in  the  lower  abdomen,  as  was  noted  in  Case  1)013.  Others  have  par- 
oxysmal {jain  in  the  lower  abdomen,  or  a  sharp  ])ain  may  radiate  throughout  the 
entire  abdomen,  as  in  Case  1151.  Coitus  may  cause  pain,  as  was  noted  in  Case 
2772. 

Pain  referable  to  uterine  myomata  may  be  divided  into  two  classes: 

1 .  Pain  in  the  uterus  itself. 

2.  Pain  as  a  result  of  pressure  on  the  surrounding  j)elvic  structures. 
Pain  in  the  T  t  e  r  u  s  Itself  . — The  uterine  pain  may  be  intermittent 

or  continuous,  and  is  usually  most  severe  at,  or  just  before,  the  menstrual  period. 

In  Case  4972  the  uterus  was  excpiisitely  tender,  and  in  Cases  4975  and  6133 
it  was  painful  at  or  near  the  menstrual  ])eriod. 

Labor-like  pains  were  ex])erienced  in  Cases  b551,  1966,  2052,  3066,  3111, 
416S,  52S9.  In  Case  52(S9  they  occurred  when  the  hemorrhage  was  severe. 
In  Case  4168  the  ])atient  said  that  when  the  j)ains  came  on  she  felt  "just  as  if 
the  child's  head  was  about  to  be  boi-n." 

Pressure  Pains  . — In  addition  to  an  ill-defined  abdominal  discomfort 
and  general  abdominal  pain,  we  may  find  many  definite  pressure  symptoms.  Pain 
in  the  back  and  hips  is  frequent.  AMiere  there  is  much  pressure,  there  is  liable 
to  be  localized  pain,  as  in  Cases  21 58  and  2838.  in  which  the  patients  experienced 
severe  pain  in  the  region  of  the  left  thigh  and  hip.  The  )\ain  may  be  dull  and 
boring  in  character,  as  in  Case  5014,  or  sharp  and  lancinating. 


THE    SYMPTOMS    ASSOCIATED    WITH    ITEKIXE    MYOMATA.  449 

C'oiitiiiiied  pressure  on  the  pehic  nerves  causes  discomfort  in  one  and  some- 
times in  both  legs.  For  example,  in  Case  4016  there  were  cramp-like  pains  in 
the  legs  and  feet ;  in  Case  13016  there  was  aching  in  both  legs.  In  Case  9924 
the  pain  in  the  right  leg  was  so  severe  that  the  patient  at  times  was  forced  to 
remain  in  bed. 

The  pain  in  the  leg  and  foot  has  been  mistaken  for  rheumatism,  as  in  Case 
8943. 

In  other  cases  the  pressure  interferes  with  the  sensation  of  the  extremities. 
Thus  in  Case  3583  the  patient  complained  of  numbness  in  the  right  leg;  in  case 
8266  in  the  outer  side  of  the  left  leg,  and  in  Case  1329  in  both  legs.  In  Case 
694  the  pressure  was  so  severe  that  there  was  loss  of  sensation  in  the  left  leg. 

Only  in  rare  instances  does  the  pressure  of  the  tumor  ])eeome  excessive,  but  in 
Case  3199  the  pelvic  pain  was  so  severe  that  the  patient  was  comjielled  to  give 
up  work  and  remain  in  bed  for  eleven  days,  and  in  Case  1212  the  patient  was  con- 
fined to  her  bed  for  five  months. 

In  Case  3338  the  paroxysms  of  pain  were  so  severe  that  the  patient  had  con- 
vulsive attacks,  and  in  Cases  3353  and  4828  there  was  loss  of  consciousness 
also. 

The  effects  of  pressure  on  the  Idadder  and  on  the  rectum  will  be  discussed 
under  ^licturition  and  Defecation. 

In  only  one  instance  (Case  12369)  was  there  pain  in  the  breasts. 

Condition  of  the  Breasts  in  Cases  of  Uterine  Myoma. — In  the  vast  m.ajority 
of  cases  the  breasts  show  no  change,  and  the  myomata  seem  to  have  little  or  no 
influence  on  these  organs. 

The  following  changes  have  been  noted : 

1.  Colostrum  in  the  breasts. 

2.  Small  benign  breast  nodules. 

3.  Carcinoma  of   the   breasts. 

Colostrum  in  the  Breasts  . — In  two  of  our  cases  the  breasts 
contained  fluid.  ai){)arently  colostrum. 

In  Case  1 1392  a  n egress,  aged  thirty-foui',  had  liccn  iiiai-ricd  tlii'cc  years  but  had 
riev^er  been  pregnant.  The  myomatous  uterus  was  ihc  si/c  of  that  of  a  sc\('ii 
months' pregnancy  ;  tlie  ccrN'ix  was  hard.  The  l)r('asts  were  hard,  but  contained 
colostrum. 

In  Case  12154,  a  negress  aged  thirty -sexcii.  although  mai'iMcd  se\-ei'al  years, 
had  never  l)een  pregnant.  A  multimxhihii'  myomatous  uterus  i-eached  -I  cni. 
above  the  umbilicus.  The  cei-vix  was  very  soft  and  (lisphu'(>(l  downward  and 
backward.     The  breasts  contained  colostriun. 

We  are  at  a  loss  to  account  foi-  the  colosl  lann,  ;is  in  neithei-  ease  (hd  jifegnaney 
exist.  The  diagnosis  between  a  unifoi'inly  enlarged  and  soft  niyoiuatous  uterus 
and  pregnancy  is  often  (lillicuh,  and  the  presence  of  eolostrum  in  the  breasts  is 
strong  presunipti\'e  exidence  of  pi-egnancy.  Xe\-ertheless.  in  rai'e  instances 
colostrum  may  be  present  when  no  pregnancy  exists. 
29 


450  MVOMATA    OF   THE    UTERUS. 

S  m  a  11  Benign  Breast  T  u  in  o  r  s  . — In  Case  1558  a  small,  semi- 
fluctuant,  and  apparently  l^enign  tumor  was  found  in  the  left  breast.  The 
uterus  contained  numerous  myomata,  antl  there  was  sarcoma  of  the  peripan- 
creatic  lymph-glands  (Aut.  Xo.  353).  Xo  operation  was  performed  on  account 
of  the  debilitatetl  condition  of  the  patient. 

In  Case  1637  there  was  a  small  myomatous  uterus  and  a  large  ovarian  cyst 
shoeing  irregular  carcinomatous  changes.  The  patient  had  had  a  small  tumor 
in  one  breast  for  twenty  years. 

C  a  r  (•  1  n  <)  m  a  o  f  t  h  e  B  r  east  . — In  Case  3426  the  patient  entered 
the  hospital  with  a  sloughing  submucous  myoma.  This  was  removed,  but  the 
patient  died  on  the  .seventh  day.  Autop.sy  showed  that  death  was  due  to 
rupture  of  a  preexisting  pus-tube.  Eighteen  months  j)rior  to  her  admission 
one  breast  had  been  removed  for  carcinoma. 

In  Case  C.  H.  I.  Xo.  78  the  patient  entered  the  hospital  on  account  of  the 
pressure  symptoms  produced  l)y  a  i)elvic  tumor  which  proved  to  be  a  myoma 
undergoing  sarcomatous  transformation  fp.  184). 

She  also  had  carcinoma  of  one  breast,  but  refused  to  have  it  removed. 
Four  years  later  she  returned  with  inoperable  growths  in  both  breasts. 

Carcinoma  of  the  breast  must  be  looked  upon  as  an  accidental  accompaniment 
of  uterine  myomata,  the  one  being  in  no  way  responsible  for  the  other. 

Effect  of  the  Tumor  on  Respiration. — With  the  increase  in  the  size  of  the  tumor 
the  patient  often  notices  thai  her  clothes  are  getting  tight.  Later,  the  tumor 
may  interfere  with  walking,  and  when  the  myomatous  uterus  almost  fills  the 
abdomen,  the  abdominal  organs  so  impinge  on  the  diaphragm  that  the  lungs 
are  partialh'  compressed  and  the   patient   complains  of  shortness  of  breath.* 

In  Case  C.  H.  I.  McA.,  in  which  the  myoma  weighed  more  than  the  patient 
(Fig.  316.  p.  513),  it  was  impossible  for  her  to  he  on  her  ])ack.  If  by  chance 
she  got  over  on  her  back,  she  had  at  once  to  call  for  assistance  on  account  of 
almost  complete  suffocation.  \Mien  the  interference  with  breathing  is  due 
to  the  tumor,  respiration  becomes  n()fni:d  as  soon  as  the  growth  is  removed. 

The  shortness  of  breath  may  also  be  due  to  the  excessively  low  hemoglobin, 
caused  by  great  loss  of  blood  from  the  myomatous  uterus.     (See  p.  453.) 

Edema  of  the  Lower  Extremities. — In  45  cases  edema  was  noted.  Sometimes 
it  involved  one  ff)ot  or  ankle,  and  in  severe  cases  the  knee;  in  other  cases  both  legs 
were  swollen.     The  edema  ai)j)eared  to  be  due  chiefly  to  the  following  factors: 

1.  Pressure  exerted  by  the  tumor  upon  the  pelvic  veins. 

2.  A  low  hemoglol)in  percentage,  with  a  w'eak  heart's  action. 

3.  Renal  insufhcienc^^ 

Pressure.  — ^^Tlen  the  edema  of  the  legs  was  due  to  pressure  by  the 
tumor  upon  the  pelvic  veins,  the  swelling  was  sometimes  unilateral;  in  other  cases 
both  legs  were  involved.     In  Case  8542   the  edema  was  confined  to  the  right 

*Shortness  of  breath  was  noted  in  Cases  121.  6.39.  1(372.  1.S62.  207.3.  2713,  2S22,  3111,  i314, 
4828,  5617,  5987,  6418,  9786,  and  9915. 


THE    SYMPTOMS    ASSOCIATED    WITH    UTERINE    MYOMATA.  451 

leg.  In  Case  4599,  at  first  the  right  leg  alone  was  edematous,  but  with  the  in- 
crease in  size  of  the  tumor  the  swelhng  came  to  involve  both  legs.  In  Cases  83G8, 
9138,  9928,  and  11944  the  edema  was  hmited  to  the  left  leg. 

Myomata  often  move  about  to  a  limited  extent,  and  as  a  consequence  the 
pressure  upon  the  pelvic  veins  may  be  temporarily  or  permanently  relieved,  and 
the  edema  disappear.  In  one  case  edema  of  the  ankles  had  been  noted  seven 
3'ears  before  the  patient's  admission,  but  with  the  increase  in  the  growth  of  the 
tumor  the  edema  had  disappeared  permanently. 

In  Cases  6441  and  10199  the  edema  also  completely  disappeared  with  the 
alteration  in  position  of  the  tumor. 

The  relief  of  the  pelvic  veins  from  pressure  may  be  intermittent — hence  the 
occasional  edema  noted  in  Cases  1685  and  3444. 

A  Low  Hemoglobin  Percentage.  — Submucous  myomata  often 
cause  alarming  uterine  hemorrhages,  and  as  a  result  the  percentage  of  hemoglobin 
rapidly  diminishes.  In  Case  12234  the  hemoglobin  was  25  per  cent. ;  in  Case 
9678,  23  per  cent. ;  in  Case  9707,  22  per  cent. ;  in  Case  9786,  20  per  cent.,  and  in 
Case  9593,  10  per  cent.  With  a  very  low  hemoglobin  the  heart  muscle  cannot 
receive  the  necessary  nourishment,  and  a  more  or  less  marked  grade  of  cardiac 
dilatation,  wdth  edema  in  the  extremities,  is  the  natural  consequence.  That  the 
cardiac  murmurs  due  to  the  dilatation  are  merely  functional  is  clearly  shown  by 
the  rapid  recovery  of  patients  after  the  removal  of  the  cause  of  the  hemorrhage. 
Thus,  in  the  absence  of  organic  cardiac  disease,  after  a  few  weeks  the  change  in 
the  patient  is  marvelous,  and  in  the  course  of  a  month  or  two  the  cardiac  area 
becomes  normal  in  extent,  the  heart's  action  regular,  and  all  the  murmurs 
vanish.  In  Cases  6017,  9593,  9678,  and  12154,  in  addition  to  a  low  hemoglobin 
percentage,  there  were  definite  cardiac  symptoms. 

When  the  edema  is  the  result  of  a  lack  of  hemoglobin,  Ijotli  legs  are  usually 
enlarged. 

Renal  Insufficiency.  — In  three  of  our  cases  the  edema  was  ap- 
parently attributable  to  renal  insufficiency.  In  Case  1383^- the  urine  contained 
albumin,  but  no  casts  were  detected.  Edema  was  present,  and  the  abdominal 
cavity  contained  ox'cr  14,000  c.c  of  ascitic  fluid. 

In  Case  2713  the  abdominal  walls  wci'c  cdeniatous.  and  (he  ui'ino  contained 
hyaline  and  (^j)ithelial  casts. 

In  Case  0  (Hebrew  Hospital,  .hily  11.  1!)02)  the  i)ali(Mit"s  legs  for  several 
days  had  been  greatly  swollen  and  had  turned  pui'ple.  The  ui'ine  contained 
<|uantities  of  albumin  and  was  loaded  with  casts. 

The  Condition  of  the  Heart. — Much  has  been  said  about  the  \ai"ious  cardiac 
changes  that  at'c  due  to  oi"  associated  with  ul<'i-iiic  myomata,  ;iii(l  ;i  great  deal  of 
confusion  exists  as  to  the  roh'  |)layed  li\'  luyoiuata  in  the  ile\'elopinent  of  he.art 
lesions. 

In  92  of  our  cases  we  haxc  data  iiiihcating  iiiip.aii'eil  cardiac  action. 

Varietv    of    Cardiac    Sounds.      The   abnormal    cardiac    sounds 


452  MYO.MATA    OF    TIIK    UTERUS. 

have  been  manifold  and  varied.  In  Case  TSoO,  for  instance,  a  soft  systolic 
niurnmr  could  i)0  heard  over  the  entire  precordial  area.  In  Case  7G8S  the  first 
sound  over  the  entire  heart  had  a  rather  snapi)ing,  hollow,  tympanitic  quahty. 
In  Case  13039  a  soft,  blowing  murmur  was  heard  all  over  the  base  of  the  heart. 
The  murmur  was  very  intense  in  the  second  left  intercostal  space,  and  was 
probably  diastohc.  A  diastolic  ruinl)le  was  noted  in  Case  7240.  Soft,  systolic, 
pulmonic  nun-murs  were  noted  in  Cases  6722,  7266,  and  7295,  and  a  loud,  sys- 
tolic, pulmonic  murmur  in  Case  9769. 

Systolic  murmurs  at  the  base  were  also  found  in  Cases  6843,  7630,  12165, 
12234,  12293,  and  12964. 

Reduplication  of  the  first  sound  over  the  jnilmonic  area  was  detected  in  Case 
7216,  and  at  the  apex  in  Case  7014. 

In  Case  13025  the  heart  was  enlarged,  no  thrill  could  be  detected,  but  there 
was  a  prolonged,  blo\Aing,  systohc  murmur  at  the  apex. 

We  have  cited  a  few  cases  to  d(>monstrate  the  great  variety  in  the  character 
and  location  of  the  heart-murmurs. 

In  the  majority  of  the  cases,  however,  an  a{)ical  svstohc  murmur  was 
all  that  could  ])e  detected.  This  nmrmur  was  usually  very  soft  in  character. 
In  some  it  was  limited  to  the  apex,  but  in  others  could  be  traced  to  the  axilla, 
and  in  some  patients  to  the  base  of  the  heart. 

In  a  few  cases  the  murmur  was  harsh.  In  Case  8495  the  prominent  systolic 
nnuMuur  at  the  apex  was  associated  with  a  goiter.  This  patient  comj)lained  of 
l)alj)itation  and  shortness  of  breath. 

In  Case  C.  H.  I.  392  and  Gyn.  No.  7569  presystolic  nuu'niurs  were  present  at 
the  apex. 

Cause  of  -M  u  r  m  u  r  s  .  — Among  the  first  writers  to  mention  the  as- 
sociation of  mycjinata  and  cardiac  lesions  were  Hofmeier*  and  Fehling.f 

In  many  of  the  cases  studied  by  them  there  was  cardiac  dilatation,  espt'cially 
of  the  right  auricle,  while  the  heart  muscle  showed  brown  atro|)hy  antl  fatty 
degeneration. 

On  referring  to  the  chai)ter  on  Autopsies  (p.  394),  it  will  be  sec^n  that  in  two 
of  our  cases  myocarditis  was  present,  but  that  in  neither  of  them  was  it  clear  that 
the  myoma  had  been  the  causative  factor.  Our  clinical  material,  however, 
sheds  nmcli  light  on  the  subject.  In  nearly  all  the  cases  in  which  cardiac  lesions 
were  present  the  patient  gave  a  history  of  menorrhagia,  often  associated  with 
intermenstrual  l)leeding.  These  patients,  as  a  rule,  stood  the  anesthetic  and 
the  operation  well,  and  in  a  comparatively  short  time  they  had  gained  much 
in  strength,  and  their  cardiac  murmurs  had  disappeared.  Some  authorities 
claim  that   tlic  myoma  in  itself  brings  about  cardiac  changes.     If  such  were  the 

*"Zur  Lehre  vom  Shock,"  Zeitsch.  f.  (Icl).,  1885,  xi,  S.  366. 

f'Beitrage  zur  operativen  Behandlunjj;  d.  Utenismyome,"  Wiirtcnihurg.  med.  Correspond- 
enzbl.,  1887. 


THE    SYMPTOMS    ASSOCIATED    WITH    UTEHIXE    MVOMATA.  453 

case,  then  the  larger  the  myoma,  the  more  pronomiced  .should  be  the  cardiac 
murmurs.  This  has  not  been  our  experience.  The  largest  tumors  have  not 
been  associated  with  any  cardiac  symptoms,  but  the  heart  complications  have 
almost  invariably  been  associated  with  copious  bleeding  from  the  uterus. 

Most  of  the  murmurs  noted  in  our  cases  were,  at  the  time,  considered  to  be 
functional.  With  the  continued  loss  of  blood  the  ])atient's  vitality  is  lowered, 
and  the  amount  of  hemoglobin  materially  decreased.  The  coronary  vessels  ac- 
cordingly furnish  the  heart  muscle  with  an  inferior  quality  of  blood,  and,  as  a 
result,  the  heart  is  not  able  properly  to  cope  with  the  situation,  and  there  is,  in 
consequence,  a  slight  dilatation  of  the  chamber,  causing  the  murmurs.  After 
operation  there  is  naturally  no  more  hemorrhage.  A  relatively  normal  per- 
centage of  hemoglobin  is  soon  reached,  and  the  heart  muscle  once  more  receives 
a  healthy  blood-supply.  The  heart  contracts  to  its  normal  size,  and  the  hemic 
or  functional  murmurs  disappear. 

Our  experience  coincides  with  the  view  expressed  by  Leopold,*  that  the  cardiac 
changes  are  usually  functional  and  are  a  direct  result  of  the  anemia  caused 
by  the  uterine  hemorrhage. 

There  are,  of  course,  a  certain  number  of  cardiac  lesions  that  are  in  no  way 
caused  by  myomata.     These  still  persist  after  operation. 

In  Cases  7569  and  13039  the  previous  history  of  ''acute  rheumatic  fever"  was 
given,  and  in  Case  6272  the  cardiac  lesion  was  associated  with  nephritis  and  as- 
cites. In  Case  5010  there  was  a  chronic  pericarditis.  This  patient  was  in  a 
precarious  condition  on  entering  the  hospital.  An  attempt  was  made  to  build 
her  up,  but  she  grew  rapidly  worse.  Operation  was  undertaken  as  a  last  resort, 
but  the  patient  died  on  the  table. 

In  only  a  few  cases  has  a  cardiac  lesion  been  so  severe  that  operation  could 
not  be  undertaken  with  safety. 

A  Low  Hemoglobin  Percentage  Associated  with  Uterine  Myomata. — In  the 
accompanying  table  we  have  given  22  cases  in  which  the  hemoglobin  was  40  \)cr 
cent,  or  less  at  the  time  of  admission  to  the  hospital.  The  loss  of  hemoglobin 
in  nearly  all  the  cases  is  due  directly  to  the  frecjuenl  iu\d  often  contimious 
uterine  hcniorrhages  caused  by  tlic  myomata. 

.\n()MA   CASIIS  SHOWIXC.   A  VERY    I.OW    i'i:i!('i;.\  rA(  ;!■;  Ol'   Uli.MOCl.oI^l.X. 


GvN.  No. 

Presence  of  Sub- 

UlvMOULUHlN.               MlTfOlS     MyOMATA. 

OpKiiAiKiN.                   Hi:sri.T. 

11  yst  erect  (Ciiy.          l\ecn\ery. 

N'ai^iiin!  inyninec       i!ec()\-ery. 

tomy. 
I  lystei-ectiiiny.          Ivccdxcry. 
Ilystcrtcluiiiy.         Uecu\  ery. 

1 

l{  IM  MIkS. 

27  1 1 

3()()6 

661") 

7438 

39  |)('r  cent.            Multiple         myo- 
ni;it:i.       .\(l(Mi()- 

IllVDIlKl. 

24         "                  Suhiimcous. 

30 

19         "                  Sul)iinic(nis. 

_ 

*  Areliiv  f.  (Ivn.,   IS<)I),  I'-d.  wwiii.  S.   1. 


454  MYOM.\T.\    OF   THK    UTERUS. 

Myoma  Cases  Showixg  a  \'eky  Low  Pekcext.^ge  of  Hemoglobin. — {Continued.) 


Gtn.  No. 

Hemoglobin. 

39  per  cent. 

Presence  of  Sub- 
mucous Myomata. 

Oper.^tion. 

Result. 
Recovery. 

Remarks. 

7615 

Submucous. 

Vaginal  myomec- 

tomy. 

8804 

20 

Submucous,  fever 

Evacuation  of 

Died      eigh- 

In desperate 

for  two  weeks; 

uterine     con- 

teen hours 

cone  i  t  i  on 

later    clotted 

tents. 

later. 

when  brought 

blood  in  uterine 

to  hospital. 

cavity. 

8936.  1  .. 

i:> 

9203.  J  .. 

Returneil    with 
hemoglobin 
46  per  cent. 

Submucous. 

Hysterectomy. 

Recovery. 

8951 

3')  per  cent. 

Hysterectomy. 

Recovery. 

9593 

10    per    cent.; 
after          iron 
and     arsenic. 
21  per  cent. 

Submucous. 

Hysterectomy. 

Recovery. 

Hemoglobin  48 
per  cent,  on 
discharge. 

9678 

23  per  cent. 

Submucous. 

Hysterectomy. 
Evacuation     of 
tubo  -  ovarian 
abscess. 

Recovery. 

9707 

22 

Submucous. 

Hysterectomy. 

Recovery. 

Hemoglobin  45 
per  cent,  on 
discharge. 

9786 

20  per  cent,  on 
admission: 
before  opera- 
tion,   43    per 
cent. 

Submucous. 

Hysterectomy. 

Recovery. 

Hemoglobin  52 
per  cent,  on 
discharge. 

10172 

29     per    cent.; 
tonics,  rest  in 
bed ;     44    per 
cent,      before 
operation. 

Submucous. 

Hysterectomy. 

Recover^'. 

Hemoglobin  53 
per  cent,  on 
discharge. 

11139 

28  per  cent. 

Hysterectomy. 

Recover}'. 

11337 

12     per     cent. 
Severe  bleed- 
ing from  nee- 
dle-prick. 

No  operation. 

Died    in   ten 
days. 

11889 

14     per     cent. 

Submucous,      in- 

Partial    removal 

Recover^'. 

Delirium; 

fected. 

of     submucous 

temperature 

tumor. 

104°;     respir- 

ations,    40 : 

seemed  mori- 

bund. 

12234 

25  per  cent. 

Multinodular,  al- 
so submucous. 

Hysterectomy. 

Recovery. 

12890 

25 

Submucous. 

Hysterectomy. 

Recovery. 

Hemoglobin  55 
per  cent,  on 
discharge. 

San.  1837  . 

30 

Interstitial. 

Hysterectomy. 

Died  on  fifth 
day.     Par- 
alysis      of 
small  bow- 
el. 

Recovery. 

San.  1868  . 

30 

Multinodular,  al- 

Hysterectomy. 

so  submucous. 

San.  1944  . 

40 

Adenomyoma. 

Hysterectomy. 

Recovery. 

Path. 6421 

30         " 

Sul)mucous.   .sar- 
comatous     de- 
generation. 

Hy.st  erect  omy. 

Recovery; 
well  for  two 
years. 

THE    SYMPTOMS    ASSOCIATED    WITH    UTERINE    MYOMATA.  455 

One  cannot  safely  rely  on  the  patient's  general  appearance  for  an  index  of  the 
anemia.  For  example,  in  C.  H.  I.  728  the  patient  was  very  thin,  pale,  anemic, 
and  apparently  had  a  hemoglobin  of  approximately  40  percent.  Tests,  how- 
ever, showed  it  to  he  79  per  cent. 

In  14  of  the  tabulated  cases  the  hemoglobin  (taken  with  the  Dare  instmment), 
on  admission  to  the  hospital,  was  under  30  per  cent.,  and  in  4  of  this  number 
15  per  cent,  or  under.  For  example,  in  Case  8936  it  was  15  per  cent. :  in  11889, 
14  per  cent. ;  in  11337,  12  per  cent.,  and  in  9593,  only  10  per  cent. 

Dr.  Henry  T.  Hutchins,  formerly  Resident  Gynecologist  in  the  Johns  Hopkins 
Hospital,  has  gone  very  carefully  into  the  subject  of  the  ''Clinical  Effects  of  Sur- 
gical Anesthesia  and  Operation  upon  Anemic  Patients,"*  and  by  his  tabulation 
has  shown  clearly  how  by  rest,  fresh  air,  and  careful  nourishment,  supplemented 
by  Blaud's  pills.  Fowler's  solution,  tincture  of  nux  vomica,  etc.,  the  patient's 
hemoglobin  may  be  much  increased  in  the  course  of  a  few  weeks  or  months. 

In  Case  9593.  although  the  hemoglobin  on  admission  was  only  10  per  cent., 
by  the  above  methods  it  was  increased  to  21  per  cent,  before  operation.  Simi- 
larly, in  Case  8936  it  was  increased  from  15  per  cent,  to  46  per  cent.,  in  Case  9786, 
from  20  per  cent,  to  43  per  cent.,  and  in  Case  10172,  from  29  per  cent,  to  44  per 
cent. 

All  such  patients  need  especial  care  on  the  part  of  the  surgeon.  Some  enter 
the  hospital  just  after  a  ])ei'iod  which  has  been  exhausting,  and  an  operation 
would  be  fraught  with  great  danger.  With  the  appropriate  treatment  there  is'a 
steady  increase  in  the  hemoglobin,  but  if  the  operation  is  too  long  delayed,  the 
next  period  may  be  so  excessive  that  the  patient  may  be  even  weaker  than  when 
admitted  to  the  hospital. 

In  some  cases  immediate  operation  oftc^n  affords  the  only  chance  for  saving 
the  patient's  life.  In  Case  11889,  for  example,  reported  in  full  on  p.  577,  the 
patient  entered  the  hospital  almost  moribund.  There  was  marketl  delirium,  a 
temperature  of  104.2°  F..  with  a  pulse  of  140  and  respirations  of  40.  The 
hemoglobin  was  14  per  cent.,  and  the  heart  showed  marked  signs  of  iusuthciency. 
She  was  stimulated  for  a  few  hours,  and  the  necrotic  and  ofl'cnsivc  ))()rtions  of 
a  submucous  myoma  were  then  removed.  Two  years  later  the  patient  wrote: 
"My  health  is  better  than  ever."  This  cas(>  demonstrates  what  brilliant  results 
may  occasionally  be  obtained  even  imder  most  adverse  circumstances. 

In  Ca.se  11337  we  have  an  example  of  the  ))rofound  anemia  that  sometimes 
results  when  an  intact  or  sloughing  submucous  myoma  is  present.  Six  months 
before  the  patient's  admission  uterine  hemorrhages  had  commenced  and  had  been 
almost  contimious,  and  foi'  the  last  thice  months  she  liad  been  I'oiccd  to  icniain 
in  bed.  On  admission  the  inucous  nienihraiies  wei'e  very  pale,  ihc  hemoglobin 
was  12  per  cent.,  and  the  red  coi'puscles  were  l.S2S,()0();  there  were  functional 
cardiac  murmurs  and  a  temperature  of  102°  1'.  When  blood  was  drawn  from 
the  ear  for  making  the  blood  count,  the  needle-piick  lih'd  so  ))rofusely  that  a 

*  Henry  T.  Hutcliins.  .1.  11.  11.  Hull..  MMll.  vol.  xv,  p.  :^')*t. 


456  MYOMATA    OF    THE    UTERUS. 

compress  had  to  be  applied,  and  vwn  adrenalin  did  not  .>^top  the  How.  Opera- 
tion was  impossible,  and  the  patient  died  on  the  I'onrth  day.  Autopsy  revealed 
fatty  degeneration  of  the  heart  and  othei-  organs,  focal  necroses  in  the  liver,  and 
a  healed  infarct  of  the  spleen. 

In  Case  8804  for  nearly  four  years  the  j)atient  had  had  fre([uent  uterine 
hemorrhages,  and  for  thri'e  weeks  prior  to  admission  contiiuious  l)!eeding.  Since 
that  time  she  had  grown  ])rogressively  weaker,  antl  for  the  last  two  weeks  had 
had  fever.  On  admission  she  looked  des])erately  ill,  the  respirations  were  shallow, 
and  there  was  a  blowing  systolic  nuu-mur  over  the  apex;  hemoglobin,  20  per  cent. 
The  abdomen  was  greatly  distended  by  the  myomatous  ut(>rus.  The  uterine 
discharge  was  so  offensive  and  free  that  under  light  anesthesia  the  cavity  was 
irrigated,  and  about  a  liter  of  foul  clots  brought  away.  Toward  evening  the  pulse 
became  weaker  and  weaker,  and  the  respirations  shallow  and  labored.  Death 
soon  followed. 

In  San.  No.  18o7  the  patient  liad  a  mitral  systolic  murmur,  a  hemoglobin  of 
30  per  cent.,  and  a  temperature  of  100°  F.  A  simple  abdominal  hysterectomy 
was  performed.  The  patient  did  not  do  well  frtjm  the  first,  and  died  on  the  fifth 
day.  At  autopsy  the  intestines  were  nuich  distended,  but  there  was  no  evidence 
of  infection.  For  some  unaccountable  reason  there  had  evidently  been  a  paraly- 
sis of  the  bowels. 

From  the  above  it  will  be  seen  that,  as  a  rule,  the  sim])le  lowering  of  the 
amount  of  the  hemoglobin  in  itself  need  not  deter  the  surgeon,  especially  as  by 
operation  he  is  going  to  completely  remove  the  cause  of  the  hemorrhage,  which,  if 
it  persists,  may  speedily  cause  a  fatal  issue.  When  infection  is  associated  with 
a  very  low  hemoglobin,  the  outlook  is  very  gloomy. 

Loss  of  Weight. — The  ])resence  of  myomata,  as  a  rule,  has  little  or  no  in- 
fluence on  the  general  ai)j)earance.  Some  i)atients  are  very  thin  because  they 
have  always  been  of  a  frail  l)uild.  Others  are  very  stout  and  have  been  so  for 
years.     Still  others  put  on  flesh  while  the  tumor  is  developing. 

A  few  patients  give  a  history  of  a  gradual  or  rapid  loss  of  weight  in  the  few 
months  or  years  prior  to  applying  for  treatment .  For  exam})le,  in  Case  9593  the 
patient  said  she  was  losing  weight  and  growing  weak.  In  Case  4903  there  had 
been  a  loss  of  15  ])()un(ls  in  weight  in  the  ])revious  four  months,  and  in  Case  4S77, 
oi  thirty-fi\-e  pounds  in  two  years.  An  iii(|uiry  into  the  history  of  such  cases  will 
almost  invariably  show  that  the  loss  of  weight  has  been  due  to  the  (>xcessive 
uterine  bleeding,  and  th;it  the  hemorrhage  has  been  caused  by  one  or  Tuore 
submucous  myomata.  The  loss  of  weight  in  Case  TloS  was  due  to  a  sloughing 
submucous  myoma,  and  in  ( 'asc  9078,  in  which  the  ])atient  had  lost  ;>()  pounds  in 
six  months,  it  was  fovuid  that  a  suppurating  subjx'ritoneal  myoma  had  oi)ened 
into  the  cecum.  With  the  rem(n-al  of  the  tumor  the  patient's  health  was  again 
restored  to  the  noruiah 

When  sarcoma  or  carcinoma  is  associated  with  th(>  myoma,  it  is  only  natural 
that  the  vitality  .should  be  i-apidly  und(>rmined. 


THE    SYMPTOMS    ASSOCIATED    WITH    UTERIXE    MYOMATA.  457 

Profound  Weakness. — When  there  is  great  weakness  associated  with  uterine 
niyoniata.  it  may  he  assumed  that  either  a  sul)mueous  myoma  is  giving  rise  to 
profuse  uterine  bleeding,  or  that  some  other  independent  process  is  sapping  the 
patient's  vitahty.  In  Cases  1879,  2902,  and  3437  the  patients  complained  of 
excessive  weakness,  and  in  Cases  4285,  9786,  and  10618,  in  addition  to  the  weak- 
ness there  w^ere  fainting  spells.  These  were  especially  prone  to  occur  at  or  just 
after  the  excessive  period. 

In  Case  9707  the  menorrhagia  was  so  ])rofuse  that  the  hemoglobin  was  re- 
duced to  22  per  cent.,  and  the  patient  had  blurred  vision  following  the  periods. 

In  all  the  cases  in  which  we  found  such  marked  lowering  of  the  vitality  the 
asthenia  was  due  to  excessive  bleeding. 

The  loss  of  blood  may  be  so  marked  that  the  patient  suffers  from  air-hunger, 
as  w^as  noted  in  Case  9786.  In  a  few  of  the  cases  the  patient,  on  account  of  the 
continuous  foul  discharge  and  of  the  continuous  dribbling,  may  become  bed- 
ridden. Such  a  condition  existed  in  Case  11013,  and  the  patient  had  taken 
large  quantities  of  morphin. 

Temperature, — UncompHcated  myomata  are  rarely  accompanied  by  any 
rise  in  temperature.  When  fever  exists,  it  is  usually  due  to  absorption  from  a 
necrotic  submucous  myoma  or  a  suppurating  myoma,  to  an  infection  from  an 
accompanying  accunmlation  involving  the  adnexa,  or  to  some  complicating 
intercurrent    affection. 

The  Fertility  of  Women  Who  Develop  Uterine  Myomata. — In  1149  cases  we  have 
definite  data  as  to  marriage  and  pregnancy.  Of  this  number,  757  were  white 
women  and  392  colored. 

X.       ,  •    1      Q.o         '  White 530 

Number  married,     <S4i:       \  r^  ^        ^  oio 

(  Lolored 312 

^^       ,         .      ,  .,,,_         /White 227 

Number  single.        30.:       (colored 80 

All  but  five  of  the  married  j)atients  were  marricvl  bc^fore  they  wcM'e  foi'ty 
years   of   age. 

Out  of  the  tfttal   number  of  cases — 

584  were  sterile. 

7.5  had  had  miscarriages,  l>ut    no  tuli-tcrm  labor. 
490  iiad   lia.i  cliihh-en. 

Total 1149 

Sterile  Patients.  Of  tlie-^e,  2<)r)  weiv  mai-ried  (1S7  white:  lOS 
colored);    2S9   wei-e   single. 

Length  of  mai'i'ieil  life  of  the  29.")  sterile  patients: 

Less  than  six  montlis ■">  cases 

Six  montlis  lo  (jne  year 10 

( )ne  to  five  years .').') 

Six  to  ten  years 70 

Eleven  to  twenty  years 94 

Twenty  years  or  over 1.3 

Data  n"i)t  (.btain.-iblc  1,S       " 

29.")      " 


458  :\IYOMATA    OF    THK    ITKRUS. 

Miscarriages. — In  addition  to  the  7")  patients  that  had  miscarried 
but  had  never  been  dehvered  of  a  full-term  child  there  were  165  others  that, 
besides  going  to  term,  had  also  miscarried,  thus  making  a  total  of  240  patients 
who  hat!  had  miscarriages. 

Tainilation  of  the  numi)er  of  miscarriages  jkt  j)atient: 

1  miscarriage  in  eatli  of 1  oS  cases 

2  miscarriages  ' 51 

3  ••  "     "       " 15 

4  ••  "     "       " 8 

5  ••  "     "       " 6 

6  or  more  miscarriages  "     "       " 6 

Several  miscarriages  "     "       " 1  case 

Total,  240  cases 

In  the  great  preponderance  of  the  eases  there  was  only  one  or  at  most  two 
miscarriages,  demonstrating  that  there  was  no  decided  tendency  to  abort,  except 
in  a  few  of  the  cases. 

Tabulation  of  the  approximate  age  of  the  fetus  at  the  time  of  the  miscarriage: 

Miscarriages  occurring  during  the    first  month 3 

"                    "              "         "  second  "      41 

"  third  "     45 

"  fourth  "      18 

"  fifth  "      7 

"  sixth  "      11 

"                    "             "         "  seventh  "      5 

130 

In  1 10  cases  the  montli  was  not  gi\en 110 

240 

As  seen  from  the  tabulation,  the  greater  numl)er  of  miscarriages  aj)parently 
occurred  tluring  the  .second  and  third  months. 

In  order  to  study  the  effect  of  myomata  on  conce})tion  we  have  made  a 
tabulation  of  the  length  of  time  l)etweeii  the  miscarriage  and  the  patient's  en- 
trance to  the  hospital  for  operation. 

Miscarriages  occurring  within  five  months  of  the  operation       13  cases 

"                  "            "  six  to  eleven  "     "     "           "          10  " 

"                  "           "  one  vear  before                     "          4  " 

"   twoVears    "                          "          10  " 

"  three     "       "                          "          10  " 

"  four       "       "                          "          9  " 

"                  "           "   five  to  ten  years  before       "          56  " 

"                  "           "  eleven  to  twenty  years  before  operation 59  " 

"                  "           "  twenty  years  before  operation 26  " 

Data  not  given 43  " 

240      " 

In  only  .six  of  these  was  any  cau.se  as.signed  for  the  miscarriage.  In  three  of 
these  it  was  instrumentally  induced,  and  in  the  remaining  three  was  ascribed 
to  a  fall. 

The  table  seems  to  indicate  that,  as  the  myoma  increased  in  .size,  the  tendency 
to  conception  lessened. 


THE    SYMPTOMS    ASSOCIATED    WITH    ITEKIXE    MYOMATA. 


459 


PATIF.XTS    WHO    HAD    BORNE    CHILDREN    PREVIOUS   TO   OPERATION   FOR 

UTERINE    MYOMATA. 


1  child 

2  children 
3 

4 
5 
6 
More  than  6 


Table  of  the  Number  of  Childkex. 
each  in     184  cases 


104 
59 

.  51 
26 

.  15 
51 

490 


In  only  seven  out  of  the  490  cases  was  a  child  born  within  a  year  prior  to 
operation. 

In  Case  12725  the  patient  had  had  two  children,  one  miscarriage,  and  an 
extra-uterine  pregnancy. 

The  foregoing  statistics  are  interesting  in  a  general  way,  demonstrating  that 
over  half  of  all  the  patients  had  never  been  pregnant.  After  excluding  the 
307  who  on  account  of  their  being  single  were  of  necessity  sterile,  we  still  have 
277  out  of  a  total  number  of  842  who  were  married  and  yet  remained  sterile. 
We  have  seen  on  p.  337  that  in  myoma  cases  the  appendages  are  adherent  in  a 
large  percentage  of  cases,  and  as  this  in  itself  would  account  for  the  sterility, 
we  are  still  unable  to  say  with  any  degree  of  certainty  that  the  myoma  per  se 
was  the  direct  cause  of  the  sterility. 


CHAlTKPv  XXVT. 
OTHER  PATHOLOGIC  CONDITIONS  IN  SOME  OF  OUR  MYOMA  CASES. 

Goiter  Associated  with  Uterine  Myomata. — In  one  of  our  cases  (No.  8306) 
there  was  a  sH^lit  enlargement  of  the  thyroid,  and  in  five  other  cases*  one  or 
both  sides  of  the  thyroid  showed  a  considerable  increase  in  size.  In  only  one 
case  was  there  any  definite  sign  of  exophthalmos. 

In  four  of  the  cases  abdominal  hysterectomy  was  performed,  and  in  one  case 
a  sloughing  submucous  myoma  was  removed  by  the  vagina. 

In  one  case  (No.  4801^)  the  patient  had  a  large  goiter  on  the  right  side.  Hys- 
terectomy was  performed  on  account  of  the  myomatous  uterus,  which  filled  the 
lower  half  of  the  abdomen.  The  pulse  on  the  second  day  was  148;  on  the  third 
day  it  ranged  i)etween  13{)  and  144,  and  on  the  fourth  day  between  118  and 
132.     A  maximum  temperature  of  101°  F.  was  noted  on  the  third  day. 

In  Case  8495  the  patient  had  lost  much  blood  from  the  vagina.  She  was 
anemic,  had  a  slight  j^rotrusion  of  the  eyeballs,  palpitation  of  the  heart,  short- 
ness of  breath,  and  bilateral  enlargement  of  the  thyroid  gland.  A  soft  systolic 
murnuir  was  heard  at  the  apex.  This  replaced  the  first  sound  and  was  trans- 
mitted to  the  axilla.     The  lower  al)domen  was  filletl  with  a  myomatous  tumor. 

On  account  of  the  j)atient's  condition  s|)inal  anesthesia  with  cocain  was 
attempted,  but  ether  had  to  be  resorted  to.  The  hysterectomy  was  a  simple 
one,  but  the  patient  on  leaving  the  table  had  a  very  rapid  pulse  and  shallow 
respiration.  The  pulse  the  same  evening  and  the  next  day  ranged  between  180 
and  200,  and  then  gradually  came  down.  Later  a  severe  diarrhea  appeared. 
Convalescence  was  considerably  retarded,  but  the  patient  was  discharged  after 
four  weeks  in  a  better  condition  than  before  operation. 

The  acceleration  of  the  pulse  in  both  of  these  cases  seems  to  have  ])een  in 
a  large  measure  due  to  the  goiter,  but  the  final  results  were  satisfactory. 

Prolapsus  of  the  Uterus  Associated  with  Uterine  Myomata. — It  is  l)ut  natural 
that  prolaj)sus  and  myoma  should  l)e  associated  in  a  certain  number  of  the  cases. t 
The  descensus  may  be  slight,  moderate,  or  com])lete.  With  the  increase  in  size 
of  the  uterus  the  organ  often  is  carried  out  of  the  ))elvis  into  the  abdomen,  and 
as  a  consequence  the  {)rolapsus  may  disappear  in  part  or  com])letely  unless  there 
be  marked  elongation  of  the  cervix.  The  pr()lai)sus  is  usually  associated  with 
small  myomatous  uteri. 

In  Case  12452  there  was  an  irr(>ducible  ]irola])sus.     The  cervix  ])iT)je('ted  (>  cm. 

*Gyn.  No.  4801^,  8495,  1U5G.J.  12079.  12.V)7. 

t  Prolapsus  was  noted  in  Cases  362,  1852.  3172.  4:341.  4.337.  5248  G577,  9335,  11169,  12003, 
and   124,32 

4(30 


OTHER    PATHULCKUC    CCJXDITIOXS    IX    SOMH    OF    OUR    .MV(JMA    CASES.  461 

from  the  vagina,  and  the  pelvis  was  filled  with  a  hard  globular  mass.  At  oper- 
ation this  mass  was  found  to  be  densely  adherent  posteriorly,  and  irreducible. 

Lipoma  of  the  Abdominal  Wall  Associated  with  Uterine  Myomata. — In  Case 
7460  the  pelvis  was  filled  with  a  myomatous  uterus.  The  abdominal  walls 
were  so  thin  that  the  intestinal  movements  could  be  seen  readily.  In  the  left 
abdominal  wall  was  a  tumor  which  extended  from  the  costal  margin  to  the  level 
of  the  umbilicus.  It  was  22  cm.  long,  12  cm.  broad,  and  on  removal  proved  to 
be  a  lipoma. 

The  Condition  of  the  Umbilicus  in  Cases  of  Uterine  Myomata. — If  the  myoma- 
tous uterus  does  not  reach  above  the  pelvic  brim,  it  should  have  little  or  no  effect 
on  the  umbilicus.  But  when  the  tumor  assumes  large  proportions,  the  abdominal 
wall  is  stretched,  and  its  weakest  point,  namely,  the  umbilicus,  is  likely  to  yield. 

Obliteration  of  the  Umbilical  Depression  . — This 
condition  was  noted  in  Cases  362  and  659. 

In  Case  362  a  subperitoneal  myoma,  17  x  17  cm.,  was  adherent  to  the  abdomi- 
nal wall,  and  also  to  the  surrounding  structures.  It  is  probable  that  in  this 
case  the  tugging  of  the  abdominal  adhesions  had  gradually  unfolded  the  navel. 

The  abdomen  in  Case  659  was  greatly  distended  by  an  inoperable  cystic 
myoma.  There  was  marked  bulging  in  the  flanks,  and  total  effacement  of  the 
umbilical  depression. 

Retraction  of  the  Umbilicus  . — Only  once  in  our  series  was 
this  phenomenon  noted.  In  Case  7549  the  pelvis  and  lower  two-thirds  of  the 
abdomen  were  occupied  by  a  myomatous  growth.  The  tumor  was  apparently 
freely  movable,  but  on  moving  the  patient  from  side  to  side  the  umbilicus  would 
retract  to  the  side  to  which  the  tumor  moved.  When  the  abdomen  was  0])(>ned. 
dense  adhesions  were  encountered,  and  the  upper  part  of  the  tumor  had  become 
infected  and  had  opened  into  the  tran.sverse  colon. 

Umbilical  Hernia  . — Small  umbilical  hernia'*  are  not  infr(M|ueiilly 
associated  with  uterine  myomata.  The  opening  is  usually  small,  sometimes  just 
admitting  the  tip  of  a  finger,  but  may  reach  larg(^  pi'oportions.  as  in  Cases 
5123,  8354,  and  C.  H.  I.  F. 

As  a  rule,  the  hernial  sac  is  not  very  sensitive,  but  if  the  oincntuin  is  incar- 
cerated, manij)ulation  will  occasion  considerable  ))ain. 

Occasionally  the  incarcerated  omentum  may  become  si  i-aiigulale(l  and  under- 
go necrosis.  In  C.  H.  I.,  F.,  described  on  ]>.  120.  and  shown  in  Fig.  94,  the  abdo- 
men was  markedly  distended  by  a  large  niyoinalous  uterus.  The  umbilicus 
was  the  seat  of  a  large  hernial  sac.  The  central  poUion  of  this  was  (lai"k  I'ed, 
and  the  surrounding  tissue  very  edematous. 

When  the  abdominal  wall  is  rather  s))are  and  llie  hernial  I'in^  iiol  i)lngge(l 
with  omentum,  a  flnger  can  be  carried  thi-ongh  the  opening  and  the  surface  of 
the  myoma  palpated  over  a  con.sideral)le  area.  This  procedure  was  carried 
out  in  Cases  5092  and  12155. 

*  Umbilical  hernite  was  noted  in  Cases  1920,  4869.  5092.  rA23  (F\^.  :W1,  p.  (ilO).  ,-)94(;,  7:3.30. 
7460,  7508,  7583,  8270,  8354,  94.57.  11006.  121.55.  12696.  nnd  ('.  H,  I.  F.  (Fii?.  94.  p.  120). 


462 


MYOMATA    OF    THK    ITHIU'S. 


When  an  umbilical  hernia  complicates  a  myomatous  uterus,  it  is  well  to  begin 
the  incision  in  the  median  line  above  the  hernia.  With  the  finger  in  the  abdomen 
as  a  guide  the  entire  hernial  sac  can  be  dissected  out  rapidly  and  without  risk 
of  cutting  any  incarcerated  omentum.  With  the  sac  lying  free  it  can  be  readily 
cut  away  from  the  omc^ntum,  and  the  hysterectomy  completed  in  the  usual 
manner. 

A  S  m  all  C  y  s  t  at  t  h  c  V  m  b  i  1  i  c  u  s  . — In  Case  7688  the  lower  part 
of  the  abdomen  was  filled  with  a  myomatous  uterus.  At  the  umbilicus 
was  a  small  cyst  which,  at  first  sight,  suggested  an  incarcerated  hernia.  As 
the  specimen  was  lost  we  are,  unfortunately,  not  able  to  give  its  histologic 
jX'culiarities. 

Femoral  Hernia  Associated  with  Uterine  Myomata. — In  only  three  of  our 
myoma  cases  have  we  records  of  a  femoral  hernia.  In  two  it  was  on  the  left 
side,  in  one,  on  the  right. 

In  Case  3416  the  incarcerated  myomatous  uterus  did  not  rise  out  of  the  pelvis. 
In  Case  6129  the  uterus  reached  almost  to  the  umbilicus,  and  in  Case  11984 
the  uterus  was  as  large  as  that  of  a  six  months"  pregnancy.  It  will  thus  be  seen 
that  in  none  of  the  cases  was  the  uterus  large  enough  to  cause  any  great  tension 
on  the  abdominal  walls.  The  hernia  in  each  case  must  be  looked  upon  as  an 
accidental  accompaniment. 

Inguinal  Herniae  Associated  with  Uterine  Myomata. — The  accompanying 
table  gives  the  records  of  7  cases  in  which,  in  addition  to  uterine  myomata, 
an  inguinal  hernia  was  found.  In  two  it  was  on  the  right,  in  two  on  the  left, 
and  in  three  cases  hernia'  were  present  on  l)oth  sides.  In  none  of  the  cases 
did  the  myomata  reach  large  proportions. 

It  is  clearly  evident  that  the  association  of  the  myomatous  uterus  and  the 
hernia  in  each  of  these  cases  was  purely  accidental. 


INGUINAL   HERNIA  ASSOCIATED  WITH  UTERINE  MYOMATA. 


GyN.  No. 

Myomatous  Uterus. 

Herni.\. 

Operation. 

2763a 

Size    of     that    of     a    six 
months'  pregnancy. 

Left  inguinal. 

Abdominal   hysteromyomectomy. 

2772 

Myoma,  6.5  x  5  x  4  cm. 

Left  inguinal. 

Abdominal  myomectomy:  re- 
moval of  appendages. 

4967 

Uterus  adherent,  globular. 

Right     and     left 

Abdominal   hvsteromyomectomy, 

approximately     15     cm. 

inguinal. 

double  herniotomv. 

in  diameter. 

5871 

Reached  umbilicus. 

Right     and     left, 
apparently     in- 
guinal. 

.\bdominal   hysteromyomectomy. 

9457 

Small      adenomyoma      of 

Right  and  loft  in- 

.\l)d()ininal     hvsterectomy,      also 

uterus;      large     cyst     of 

guinal,  also  um- 

cvstectomy.  obliteration  of  her- 

ovary,   probably  carcin- 

bilical hernia. 

nia  from  within.     Radical  cure 

omatous. 

of  umbilical  hernia. 

11067. 

.Myoma,  1 1  cm. 

Riglit  inguinal. 

Abdominal  liysteromyomectomy; 
modified  Hassini  operation. 

12036 

Small  uterus  with  several 

Right  inguinal. 

.\bdominal    mvomectomv;     radi- 

very small  myomata. 

1 

! 

cal  cure  of  iiernia. 

OTHER    PATHOLOGIC    CONDITIONS    IN    SOME    OF    OUR    MYOMA    CASES.  463 

Strangulated  Inguinal  Hernia  . — In  Case  1852  there  was 
complete  eversion  of  the  anterior  vaginal  wall;  the  fundus  of  the  uterus  was 
enlarged,  and  posterior  to  it  was  an  ovoid  myomatous  mass,  6x7  cm.  Vaginal 
hysterectomy  was  performed. 

On  the  nineteenth  day  a  radical  operation  for  a  strangulated  inguinal  hernia 
was  performed. 

A  Myomatous  Nodule  Filling  a  Postoperative  Hernial  Sac. — One  patient 
(Case  662S)  entered  the  hospital  giving  a  history  of  a  previous  exploratory 
abdominal  operation.  The  entire  lower  abdomen  was  filled  with  a  multinodular 
myomatous  mass.  The  abdominal  scar  was  20  cm.  long,  and  in  one  place  reached 
5  cm.  in  width.  The  walls  had  given  way  at  some  points,  and  there  were  several 
hernial  protrusions  in  the  scar.  On  excising  the  scar  many  omental  adhesions 
were  encountered,  and  one  subperitoneal  myoma  was  found  to  be  extra- 
abdominal  and  occupying  one  of  the  hernial  sacs. 

Notwithstanding  the  universal  adhesions,  a  successful  hysterectomy  was 
accompUshed. 

Cysts  of  the  Urachus  Associated  with  Uterine  Myomata. — In  two  of  our  cases 
cysts  of  the  urachus  were  encountered  during  operation  for  myomata.  In  Case 
6722  the  cyst  was  very  small — only  3  mm.  in  diameter. 

The  bladder  in  Case  7295  reached  4  cm.  above  the  symphysis.  In  this  case 
also  a  small  cyst  of  the  urachus  was  found.  It  was  situated  just  above  the 
bladder. 

Descensus  of  the  transverse  colon  was  found  in  Case  11251.  This  con:lition 
may  occasionally  be  successfully  overcome  by  looping  up  this  portion  of  the  bow(»l, 
but  the  chances  for  permanent  relief  are  slight. 

Appendicitis. — In  the  cases  operated  upon  in  the  early  nineties  mention 
of  the  condition  of  the  appendix  was  rare,  but  in  recent  years  the  appendix 
has  been  systematically  examined  in  nearly  all  the  cases. 

The  appendix  was  removed  in  at  least  83  cases.  In  only  one  instance 
(Case  12369),  was  there  an  acute  appendicitis.  In  three  a  subacute  inflammation 
was  noted. 

In  Case  2129  the  appendix  was  adherent  to  the  right  tube.  In  Case  2S0() 
it  was  adherent  to  the  posterior  surface  of  the  uterus,  and  in  Cases  9078  and 
11392  it  had  grown  fast  to  the  myoma. 

In  several  other  cases  tlie  appendix  had  grown  fast  to  Ihc  right  a|)p(Mi(higes, 
where  there  was  a  tubo-ovarian  cy.st,  a  sal|)ingitis,  or  a  jx'lvic  ahsccv'^.s. 

In  C.  H.  I.  793,  in  adchtion  to  the  a{)j)endi('itis  there  was  a  marked  chronic 
cohtis,  hmited  chiefly  to  the  transverse  and  descending  colon. 

The  myomatous  uterus  does  not  seem  in  any  way  to  predispose  to  the  develop- 
ment of  an  appendicitis.  In  fact,  it  really  looks  as  if  an  acute  and  well-defined 
appendicitis  is  a  very  rare  occurrence  whvu  myomata  exist. 

The  question  the  surgeon  naturally  asks  himself  is,  "Shall  1  remove  the 
appendix  or  not?''     If  little  or  no  (n'idence  of  a  definite  inllarnination  is  pn^sent, 


464  MYOMATA    OF   THE    UTERUS. 

our  opinion  is  that,  when  myomectomy  is  performed,  it  is  wiser  not  to  remove 
the  api)en(Ux,  as  (les{)ite  all  precautions  the  danger  of  infection  in  myomectomies 
is  great. 

When  hysterectomy  is  j)erforme(l,  api)en(lectomy  is  indicated  if  there  is  the 
slightest  eviilence  of  inflammation,  and  if  the  hysterectomy  has  been  a  simple 
one,  even  a  normal  appendix  is  better  out.  We  have  had  at  least  one  case 
(C.  H.  I.,  A.)  in  which,  several  years  after  hysterectomy,  it  became  necessary  to 
oj)erate  ujKin  the  patient  for  an  acute  appendicitis. 

Tuberculous  Peritonitis  and  Uterine  Myomata. — The  association  of  tuberculous 
peritonitis  and  uterine  myomata  has,  in  our  experience,  been  rare.  In  Case  6991 
the  uterus  contained  several  small  myomata.  It  was  densely  adherent,  and 
tubercles  were  widely  disseminated  throughout  the  abdominal  cavity  and  also 
implicated  the  adnexa.  The  uterus  with  the  appendages  and  the  appendix 
were  removed. 

Findings  in  the  Mesentery  in  Myoma  Cases. — C  alcareous  Nodules  . — 
In  Case  7011,  after  removal  of  the  multinodular  myomatous  uterus,  a  calcareous 
nodule,  2  x  2.5  x  3  cm.,  was  carefully  shelled  out  of  the  mesentery  of  the  ileum, 
about  10  cm.  from  the  ileocecal  valve.  Two  similar  but  smaller  ones  were 
removed  from  the  mesentery  a  short  distance  further  on.  The  three  openings 
were  closed  with  catgut,  great  care  being  exercised  to  avoid  injury  to  the  blood- 
vessels. 

An  Abnormally  Long  Mesentery  . — In  Case  69  the  woman 
died  five  days  after  the  hysteromyomectomy.  The  mesentery  of  the  ileum 
was  very  long.  X'olvulus  had  taken  ])lace.  with  the  subsecjuent  development 
of  f)eritonitis. 

Abnormal  Conditions  of  the  Liver  and  Gall-bladder. — T  h  i  c  k  o  n  i  n  g  of 
the  Left  Lobe  . — In  Case  C.  H.  I.,  W.  (  Lath.  No.  6421),  a  secondary  operation 
was  performed  on  account  of  sarcoma  in  the  cervical  stump  two  years  after  the 
primary  operation  (Fig.  130,  p.  191).  We  examined  the  liver  to  see  if  it  con- 
tained metastases.  The  edge  of  the  left  lobe  was  sharp  and  clean  cut,  but  the 
right  lolje  was  thickened  and  had  blunt  edges.  We  at  first  thought  we  were 
dealing  with  hepatic  metastases,  but  on  inspection  none  were  found. 

Adhesions  Let  w  e  e  n  the  Liver  and  the  T  u  m  o  r  . — In 
Case  3440,  in  which  the  tumor  weighed  30  pounds,  a  subj)eritoneal  ni}'onia  was 
adherent  to  the  abdominal  walls,  to  the  omentum,  and  to  the  suspensory  ligament 
of  the  liver. 

In  Case  C.  H.  I.,McA.,  in  which  an  SO-pound  myoma  was  removed,  the  tumor 
was  so  intimately  adherent  to  the  liver  that  a  jjiece  of  hepatic  tissue  came  away 
with  it. 

Gall-bladder  . — In  Case  6432  the  myomatous  uterus  iill(Ml  the  entire 
abdomen.  The  tumor  was  adherent  to  the  omentum,  mesocolon,  to  the  hepatic 
flexure  of  the  colon,  and  also  to  the  gall-bladder. 


OTHER    PATHOLOGIC    CONDITIONS    IN    SOME    OF    OUR    MYOMA    CASES.  465 

In  Cases  6792,  8514,  8667.  and  s71o.  after  removal  of  the  myomatous  uterus, 
the  gall-bladder  was  opened  on  account  of  gall-stones. 

Glycosuria. — In  only  two  of  our  cases  of  uterine  myomata  was  glycosuria 
noted  prior  to  operation.  In  Case  12291  there  was  a  multinodular  myomatous 
uterus  which  reached  3  cm.  above  the  umbilicus.  On  account  of  the  large 
amount  of  sugar  contained  in  the  urine,  operative  interference  was  considered 
inadvisable. 

In  Case  2108  the  patient  had  a  multinodular  myomatous  uterus  which  ex- 
tended almost  to  the  costal  margins.  She  had  profuse  uterine  hemorrhages  and 
suffered  from  constant  pain  in  the  right  flank  and  down  the  right  leg.  The  urine 
at  first  contained  much  sugar,  but  after  the  patient  had  been  kept  under  observa- 
tion for  two  and  a  half  weeks  the  sugar  disappeared  completely.  Three  weeks 
later  the  abdomen  was  opened;  the  intestines  were  densely  adherent  to  the 
uterus  and  to  one  another,  and  bled  freely  on  liberation.  The  appendages  were 
also  inflamed  and  adherent.  On  account  of  the  condition  of  the  patient  and  the 
desperate  chances  attending  a  hysterectomy,  the  abdomen  was  closed.  The 
patient  made  a  satisfactory  recovery. 

Shortly  after  the  operation  the  glycosuria  reappeared,  lasted  several  days, 
and  then  again  disappeared.  Had  the  symptoms  been  distressing  and  the  uterus 
free  from  adhesions,  we  would  certainly  have  removed  it,  inasmuch  as  patients 
suffering  from  diabetes  often  stand  operations  remarkal)ly  well. 

Misplaced  Kidneys  in  Cases  of  Uterine  Myomata. — Prolapsus  of  the  kidney  is 
very  common,  and  we  should  not  be  surprised  to  find  it  frequently  associated  with 
uterine  myomata.  When  the  myomata  reach  any  considerable  size,  the  abdom- 
inal capacity  is  naturally  diminished,  and  there  is  not  the  same  chance  for  a 
general  enteroptosis ;  consequently  in  very  few  of  our  cases  has  prolapsus  of  the 
kidney  been  noted  where  the  myomatous  uterus  has  been  large. 

In  Case  8197  the  myomatous  uterus  was  small  and  the  lower  pole  of  the  right 
kidney  reached  to  the  level  of  the  umbilicus. 

The  dislocation  of  the  kidney  in  Case  891  was  most  marked,  and  naturally 
led  to  confusion  on  bimanual  examination.  The  uterus  was  studded  with  small 
myomata,  and  what  was  suj)posed  to  be  a  pedunculated  sul)peritoneal  nodule  was 
felt  behind  and  to  the  right  of  the  uterus.  This  supposed  jx-dunciilated  myoma 
proved  to  be  the  right  kidney,  which  lay  within  the  jx-lvis.  being  entirely  below 
the  sacral  promontory. 

Nodules  Studding  the  Left  Kidney. — In  Case  7438,  a  white  woman,  aged 
forty-three,  had  a  myomatous  uterus  which  filled  the  jx'lvis.  After  its  removal 
the  kidneys  were  examined.  Both  were  much  enlarged,  and  the  left  was 
studded  with  nodules  varying  from  2  to  5  mm.  in  diameter.  They  were  confined 
chiefly  to  the  lower  half  of  the  kidney.  .\o  en!arge(l  lynii»h-giands  could  be 
found,  nor  was  there  any  evidence  of  growths  elsewhere  in  the  abdominal  cavity. 
Of  course,  no  microscopic  examination  of  the  nodules  could  be  made,  and  we 


'*""  MYOMATA    OF   THE    UTERUS. 


are  in  the  dark  as  to  their  nature.     The  patient  made  a  i^ood  recovery.     Her 
hemop^Iobin  at  the  time  of  operation  was  19  jjer  cent. 

Renal  Colic— In  onl}-  one  case  did  a  patient  with  uterine  myomata  give  a 
history  suggestive  of  renal  colic.  In  Case  3113,  the  woman,  aged  fifty-two,  had 
had  what  appeared  to  be  definite  symptoms  of  renal  colic  once  or  twice  a'year 
for  twelve  years  before  operation.  She  had  violent  pain,  commencing  in  the 
left  kidney  and  passing  dovra  the  course  of  the  ureter.  No  calculus  was  detected, 
but  the  urine  at  these  times  was  tinged  with  blood.  The  wax-tipped  catheter 
and  the  .r-rays  at  that  time  had  never  been  employed. 


CHAPTER  XXVII. 

DIFFERENTIAL  DIAGNOSIS. 

To  describe  ade(|uately  the  various  pathologic  conditions  that  might  have  to 
be  differentiated  from  uterine  myomata  would  necessitate  a  careful  considera- 
tion of  nearly  every  pelvic  lesion  that  can  occur  in  women,  and  many  abdominal 
lesions  would  also  require  a  detailed  description.  In  the  limited  space  at  our 
disposal  we  shall  merely  describe  those  cases  in  which  we  have  personally  found 
difficulty  in  arriving  at  a  correct  diagnosis. 


Pregnancy 

At  times  the  differentiation  between  myoma  and  pregnancy  is  clinically 
almost  impossible,  and  even  after  the  abdomen  has  been  opened,  it  is  often  diffi- 
cult to  decide  whether  the  uterine  enlargement  is  due  to  a  myoma  or  pregnancy. 
The  difficulty  is  especially  apt  to  occur  when  the  uterus  is  uniformly  enlarged. 

Menstruation.  — In  myoma  cases  the  menstrual  period  is  usually 
regular;  for  pregnancy,  cessation  of  the  period  affords  strong  presumptive  evi- 
dence. In  some  cases,  however,  the  flow  may  be  perfectly  regular  throughout 
the  period  of  gestation. 

Breasts.  — In  pregnancy  the  breasts  afford  signs  that  are  characteristic 
and  that  are  usually  wanting  in  myoma  cases.  But,  as  noted  on  p.  449,  the 
breasts  in  some  instances  are  enlarged  and  contain  fluid.  In  all  these  cases  the 
possibility  of  a  pregnancy  with  an  associated  myomatous  condition  must  be 
remembered. 

The  Cervix.  — The  characteristic  softness  of  the  cervix  in  pregnancy  is 
usually  sufficient  to  establish  the  diagnosis,  but  in  a  few  cases  the  cervix  may  be 
hard  and  firm,  and  lead  one  to  infer  that  no  pn^gnancy  exists. 

The  flail-like  manner  in  which  the  body  of  the  uterus  can  be  moved  back- 
ward and  forward  on  the  cerv'ix  is  most  characteristic  of  pregnancy,  but  in  rare 
instances  this  may  be  simulated  in  the  case  of  a  myomatous  uterus  when  the 
cervix  has  been  greatly  lengthened  out  and  attenuated  (.see  p.  442). 

Inspection  of  the  Uterus. — Prior  to  opening  the  abdomen  the  operator  has  care- 
fufiy  considered  all  these  possibilities,  and  yet  on  .seeing  tiic  uterus  its  regularity 
may  be  so  pronounced  that  he  is  .'^till  suspicious  of  j)r(>gnancy.*  Where  pr(>g- 
nancy  exists,  the  uterus  is  usually  of  a  hhiisii  hue,  due  to  the  marked  vascularity, 
and  very  different  from  the  pinkish  color  usually  seen  in  the  luyoniatous  uterus. 

*In  the  following  additional  cases  the  myomatous  litems  strongly  suggested  a  pregnancy. 
Gyn.  Nos.  1579,  4203,  5687,  7059.  72.37  8247,  and  9G7S. 

467 


468 


MYOMATA    OF   THK    UTERUS. 


In  pregnancy  also  the  vessels  passing  to  and  from  the  uterus  are  greatly  enlarged 
and  engorged. 

When  pregnancy  exists,  the  insertions  of  the  tubes  and  round  ligaments  bear 
their  normal  relations  to  the  uterus.  This  may  or  may  not  be  the  case  if  the  en- 
largement is  due  to  a  myoma. 

Where  the  cervix  is  rather  broad  and  hard  and  the  tubes  and  round  ligaments 
are  inserted  closer  to  the  center  than  they  would  ordinarily  be  in  cases  of  preg- 
nancy (Fig.  290),  myoma  will  usually  be  found.  On  the  other  hand,  if  the  in- 
sertions be  at  the  relatively  normal  site  considering  th(>  size  of  the  uterus,  it  may 
be  necessar\%  as  a  last  resort,  to  split  the  uterus  to  determine  the  cause  of  the 


:^0Sy. 


¥m^ 


Fig.    290. —  .\    Myonhtocs   Uteru.s   Closely    RESE.Mi>i,iN<.    \    Viit.<.s.\sr    Uteri-s   in   its   Ge.ner.\l  Contour. 

(fs  nat.  size.) 
-Although  the  uterus  resemble.?  a  pregnant  organ,  the  right  tube  and  right  round  ligaments  are  inserted  at  a 
higher  level  than  are  the  left  tube  and  round   ligament.     On   the  other  hand,   the  ovary  is  attac'.ied  at   a  lower 
level  than    the   ovary    on    the   left.     The  enlargement   wa.s  due    to  an   interstitial  myoma  in    the   posterior   wall. 
(.\fter  Howard  A.  Kelly.) 

enlargement.     This  we  did  in  .several  instances,  and  in  each  case  found  the  myo- 
matous tumor. 

In  Ca.se  S.,  C.  H.  I.  (June  0,  1903),  the  uterus  on  inspection  strongly  suggested 
a  four  months'  pregnancy,  although  the  history  in  no  way  indicated  it.  On  the 
one  hand,  we  did  not  want  to  disturl)  a  normal  gestation,  and,  on  the  other  hand, 
did  not  deem  it  fair  to  close  the  abdomen  when  another  operation  would  in  all 
probability  be  necessary  a  few  weeks  later.  We  accordingly  carefully  split  the 
uterine  wall  and  at  once  encountered  a  cystic  myoma,  10  cm.  in  (haineter.  This 
projected  .slightly  into  the  uterine  cavity.  A  myomectomy  was  done  and  the 
uterus  saved. 


DIFFEHKXTIAL    DIAGNOSIS. 


469 


In  Case  M.,  C.  H.  T.  f.Iaiuuiry  IS,  1900),  the  uterus  reached  to  the  unil^iHcus 
and  strongly  reseinl)l('(l  a  pi'cjinant  organ,  althougli  there  was  no  history  sugges- 
tive of  it.  The  uterus  was  carefully  cut  into,  and  the  enlargement  found  to  he 
due  to  a  ])artially  submucous  myoma.  The  myoma  was  removed,  hut  the 
organ  left. 

On  several  occasions  when  examining  the  enlarged  utems  in  the  laboratory 
we  have  opened  the  organ  with  fear  and  trepidation  that  the  op(>rator  had  pos- 
sibly removed  a  pregnant  uterus.  In  each  case,  however,  the  softness  was  due  to 
the  fact  that  the  myoma  was  edematous  or  had  undergone  cystic  changes. 


A  Myomatous  Uterus  in  Contour  Resembling  a  Fetus. 
Occasionally,  the  myomata  may  l:)e  so  arranged  that  they  resenil)le  a  fetus. 
This  was  the  case  in  Gyn.  No.  3198.     The  clinical  history  in  no  way  suggested 
))regnancy,  neither  did  the  uterus  look  like  a  pregnant  organ,  but  in  its  general 
outlines  the  tumor  bore  a  strong  resemblance  to  a  child  (Fig.  291). 


lie.   '2!)1. — A  Myom.\tous  Uterus   Reskmbi.i.ng   a   Fetis  in   its  Contouk. 
Oyii.  No.  ;5I'JS.     Path.  No.  .533.     The  greatly  enlarged  uterus  niea.sureti   U  x  13  x  21  cm.      Tlic  iKulule  just 
beliiiKJ  the  left  ovary  might  readily  have  been  mi.staken  for  the  head  on  palpation,  and  the  large  one  l)ehind  the 
right  ovary  for  the  Ijuttocks.     The  appendages  were  normal.     The  right  tube  apparently  emerges  from  a  small 
myoma.      (.After   Ilnward   .\.   Kelly.) 

The  nodule  to  the  left  might  readilv  !>('  mistaken  for  the  liead.  the  one  to  tlie 
right  for  the  buttocks,  and  the  central  i)ortioii.  consisting  of  tlie  uterus  and 
several  smaller  nodules,  Un'  the  trunk  with  the  hands  and  feet. 


Definite  Ballottement  with  Uterine  Myomata. 
This  sign  is  most  exceptional  apart  from  pi-egnancy,  in  Case  '.VAST.  howcNcr. 
it  was  clearly  made  out.  The  uterus  cdiUaineil  se\-ei-al  myomata  of  go(  dl\-  si/e. 
and  attached  to  its  sui'I'ace  were  1  wo  |)edunculaled  niyoniat.a,  the  lai'ger  b  x  S  x  10 
cm.  One  of  the  tlwee  nodules  had  four  large  omental  Ncssels  entering  it  (Fig. 
24,  J).  ;')  I ),  anil  the  abdomen  containe(l  7()()0  c.c.  of  ascitic  lluid.  Sex'eral  of  the 
nodules  gave  a  distinct  ballottement  on  bimanual  palpation.     This  was  undoubt- 


470  MYOMATA    OF   THE    ITERUS. 

edly  due  to  the  fact  that  they  were  iJinhuiculated  and  floated  easily  in  the  ascitic 
fluid.     The  ballottenient  was  the  only  sign  that  in  any  way  suggested  pregnancy. 


Death  of  Fetus  with  Suppuration:  Perforation  of  Uterine  "Walls:  Supravaginal 

hysterectomy:  recovery.* 

This  case  demonstrated  how  nature,  if  left  alone,  may  successfully  ward  off 
an  attack  of  general  peritonitis.  Here  there  were  suppuration  in  the  uterine 
cavity,  numerous  perforations  of  the  uterus, — fortunately  situated  entirely  in 
the  anteridr  wall, — and  then  a  successful  walling  off  by  the  abdominal  wall  be- 
coming adherent  to  the  uterus. 

A.  P.,  colored,  aged  twenty-one,  was  admitted  to  the  Cambridge  Hospital 
March  4,  1906.  The  patient  had  been  thought  to  be  pregnant  one  year  before. 
She  had  been  carefully  watched  for  some  time,  but  no  further  development  had 
taken  place.  She  had  had  some  slight  fever,  but  nothing  more  definite  could  be 
learned.  When  one  of  us  (Cullen)  examined  her  the  cervix  was  soft;  the  uterus 
was  globular,  and  lay  half-way  between  the  umbihcus  and  the  xiphoid.  The 
growth  was  apparently  somewhat  movable. 

Operation:  I  made  an  incision  over  the  growth  and  immediately  came  in 
contact  with  what  looked  like  grumous  material,  w^hich  suggested  a  suppurating 
ovarian  cyst.  As  the  tissues  were  densely  adherent,  the  incision  was  continued 
upward  and  the  general  ])eritoneal  cavity  opened.  On  loosening  the  other  ad- 
hesions we  found  the  omentum  adherent.  This  was  clamped  and  cut.  The 
tumor  was  intimately  blended  with  the  thickened  abdominal  j)eritoneuin.  It 
was  shelled  out  as  rapidly  as  [)ossible,  but  pus  oozed  from  the  surface  in  various 
directions  (Fig.  292).  I  thought  that  I  w^as  deahng  wdth  an  ovarian  cyst,  but 
was  surprised  to  find  that  it  w^as  the  enlarged  and  globular  uterus.  I  amputated 
through  the  cervix.  The  tubes  and  ovaries  were  covered  with  a  few  shght  ad- 
hesions, l)Ut  were  otherwise  normal  and  were  left  behind.  It  was  with  the 
greatest  difficulty  that  enough  jjeritoneum  was  oljtained  to  close  the  abdomen, 
as  so  many  raw  areas  had  been  left  where  the  uterus  had  been  adherent  to  the 
abdominal  wall.  A  gauze  drain  was  introduced  into  the  low^r  part  of  the  in- 
cision. The  patient  im[)roved  rapidly,  and  left  the  hospital  feeling  perfectly 
well. 

Description  of  the  Uterus. — Path.  No.  9810.  The  specimen  consisted  of  an 
irregular  and  globular  mass,  approximately  18  x  17  x  15  cm.  Its  surface  was 
everywhere  covered  with  adhe.-ions,  and  at  numerous  points  were  openings  irreg- 
ular in  shape,  and  varying  from  3  to  5  mm.  or  moi'e  in  diameter.  Through  these 
openings  quantities  of  pus  welled  out  during  the  operation.  The  pedicle  or  cut 
surface  was  4  cm.  in  breadth,  3  cm.  across,  and  in  the  central  portion  of  this  was 
the  cervical  canal.     On  opening  the  specimen  after  it  had  been  hardened  we 

*  Thomas  8.  Cullen,  A  Series  of  Interesting  (iynecologic  and  Obstetric  Cases,  Jour.  A.  M.  A., 
May  4,  1907. 


DIFFERENTIAL    DIAGNOSIS. 


471 


found  that  this  tumor  was  the  uterus  (Fig.  293).     The  wahs  varied  from  1.5  to 
4  mm.  in  thickness. 

Fetus. — Snugly  filhng  the  entire  cavity  was  a  fetus.  Its  length  from  elbow 
to  axilla  was  7  cm.,  from  elbow  to  shoulder,  8  cm.  Its  breadth  in  the  axillary 
line  was  13  cm.  Other  measurements  could  not  be  made  on  account  of  the  dis- 
tortion of  the  child,  but  it  appeared  to  be  an  eighth-month  fetus.  The  skin  was 
somewhat  macerated.     The  child  was  evidently  a  mulatto,  as  in  many  places  the 


•  I 

Fig.  292. — The  Pekkok.\ted  Pkegn.\nt  Uteru.s  as  Seen  on  Re.\iov.\l. 

Path.  No.  9810.     The  surface  is  everywliere  rough  and  covered  with  ailhesions.     In  the  lower  part  of  the  field 

i.i  the  stump  of  one  tube.     At  a,  a,  are  perforations  of  the  uterus,  whence  pus  was  seen  oozing  out;  at  b,  the 

walls  are  very  thin;   there  have  been  many  adhesions,  and   pus  is  lying  on   the  surface.     One  would   not  for  a 

moment  take  this  to  be  the  uterus,  except  for  the  presence  of  the  tube.     For  the  interior  of  the  uterus  see  Fig.  293. 


mottled  appearance  was  still  present.  At  oiIhm-  points,  however,  the  outer  skin 
had  been  rubbed  off,  and  the  surface  li;itl  die  \):\\r  .'ipix-araiicc  of  a  wliitt'  child. 
The  hair,  which  was  matted  up  again-<l  the  uleriiie  \\;ill,  was  curly  and  black  and 
several  centimeters  in  length. 

Placenta. — The  ])lacenta  occupie.l  the  lowei-  (luulraiit  of  the  uterus,  and 
projected  over  the  cervi.x ;  there  had  been  a  partial  placenta  pra'via.  The 
placenta  at  the  thickest  j)ortion  was  '2  cm.  in  thi<'kness.     .Vttached  to  the  surface 


472 


MYOMATA    OF    THK    ITERUS. 


Fig.  293. — A  Puegnant  Lii.ui-,  wiiii  ihe  Fetus  asd  Pl.\cent.\  Int.\ct.  (Nat.  size.) 
Path.  No.  9810.  F"or  the  exterior  of  the  uterus  see  Fig.  292.  After  the  uterus  had  been  well  hardened,  the 
anterior  surface  was  removed.  The  cervi.x  presents  the  usual  appearance,  and  the  uterus  is  firmly  contracted 
around  the  fetus.  The  head  lies  in  the  upper  portion.  The  left  arm  is  firmly  adherent  to  the  left  side  of  the  chest, 
and  the  skin  is  macerated  to  some  extent.  Situated  in  the  lower  part  is  the  placenta,  which  extends  slightly  over 
the  internal  os. 


DIFFEHKXTIAL    DIAGNOSIS.  473 

of  the  child,  especially  in  the  vicinity  of  the  hair,  was  nuich  friable,  yellowish 
material  that  looked  veiy  much  like  ins])issated  ])iis.  It  was  from  the  surface 
of  the  uterus  at  the  points  of  perforation  that  the  jjurulent  discharge  came 
during  the  operation. 

Sections  from  the  uterine  wall  showed  that  the  outer  surface,  at  certain  jioints. 
particularly  where  it  was  adherent  to  the  abdominal  wall,  was  covered  with 
numerous  adhesions.  On  the  protected  sitle  cuboid  cells  were  visible.  The 
muscle  in  such  areas  showed  a  great  <leal  of  small-round-celled  infiltration.  The 
inner  lining  of  the  uterus  was  much  altered.  There  were  areas  of  canalized  fibrin, 
and  also  regular  ribbons  of  hyaline  and  canahzed  fibrin.  Just  beneath  the  sur- 
face, and  on  both  sides  of  this,  were  numerous  small  round  cells  and  polymorpho- 
nuclear leukocytes.  At  a  few  points  calcified  vilH  could  be  made  out.  Decidual 
cells  were  still  in  evidence,  but  they  had  become  smaller.  There  had  evidently 
been  a  chronic  inflammation  of  the  inner  surface  of  the  uterus,  cou})led  with  an 
inflammatory  process  on  the  outer  surface  at  the  points  where  the  utems  was 
adherent  to  the  abdominal  w^all. 

In  this  case  there  had  been  death  of  the  fetus  from  some  unknown  cau.se,  and 
discharge  or  absorption  of  the  liquor  anmii.  Suppuration  had  taken  ])lace  in 
the  uterine  cavity.  At  some  points  the  uterine  walls  had  become  jxn-forated. 
and  the  pus  had  trickled  out  over  the  surface.  Fortunately  no  intestines  lay  in 
the  way,  and  the  pus  had  glued  the  uterus  to  the  anterior  abdominal  wall. 
This  is  certainly  one  of  the  rarest  conditions  met  with  in  the  literature. 


A  Dead  Fetus  Resembling  a  Myomatous  Uterus. 
Occasionally  the  patient  may  be  totally  unaware  that  she  has  been  pregnant. 
If  the  fetus  dies,  the  cervix  becomes  hard,  the  uterus  contracts  materially,  and 
there  is  often  a  slight  bloody  discharge.  In  such  cases,  if  no  definite  history  is 
obtainable,  myoma  may  be  suspected.  A  feeling  of  malaise  and  chilly  sensations, 
however,  suggests  a  dead  fetus,  and  dilatation  and  curettage  will  settle  the  tliag- 
nosis. 

Abdominal  Pregnancy  and  Uterine  Myomata.* 
In  the  following  case  there  was  a  typical  history  of  a  pregnancy  gding  on 
apparently  to  term.  Labor  i)ains  developed  and  soon  ceased,  and  the  patient 
retained  the  tumor  for  nearly  four  years  without  any  marked  discomfort.  Little 
credence  was  given  to  her  statements,  as  it  ap|)eare(l  doubtful  if  .she  knew  exactly 
what  had  ha[)pene(l.  On  bimanual  examination  the  diagnosis  lay  b(>tween  a 
myomatous  uterus  and  a  dcnnoid  cN-st.  and  cNcn  when  one  of  us  r('in(»\('d  the 
tumor,  we  thought  that  it  was  a  dermoid  cyst.  It  was  only  when  the  hardened 
specimen  was  cjpened  in  the  laboratory  that  pregnancy  was  detected.     .V  glance^ 

♦Thomas  S.  Culleii.  \  Series  of  Intere.slii)<;  ( lynecoloiiir  ;iii(i  Ohstclric  Cases,  Jour.  A.  .M.  .\., 
May  4,  1907. 


474  .MYUMATA    OF   THE    UTERUS. 

at  the  contour  of  the  tumor,  as  soon  in  Fi^.  204.  will  show  that  it  closely  simulated 
a  nn'oma  in  its  general  outlines. 

Gyn.  No.  13272,     Path.  No.  10417. 

Abdominal  1'  r  e  g  n  a  n  c  \-  o  f  1"'  our  \'  e  a  r  s  '  Duration. — 
J.  A.,  colored,  married,  aged  twenty-eight,  was  admitted  to  the  Johns  Hop- 
kins Hospital  September  27,  1906,  complaining  of  j)ain  and  sweUing  in  the 
abdomen. 

Her  general  health  had  always  been  good,  and  she  had  never  consulted  a 
physician  before.  Her  menstrual  history  was  unimportant.  She  had  been 
married  fifteen  years  and  had  had  four  children,  the  eldest  nearly  fifteen  years 
old.  The  second  child  was  deficient  mentally,  but  lived  five  years.  The  third 
was  ten,  and  the  youngest  eight,  years  of  age.  Her  labors  had  all  been  normal ; 
there  had  never  been  any  miscarriages.  For  some  years  she  had  had  a  slight 
amount  of  thick,  white,  foul-smelling  discharge,  more  marked  before  and  after 
her  menstrual  periods  than  at  any  other  time.  For  several  years  she  had  been 
constipated,  the  bowels  not  moving  for  two  or  three  days  at  a  time.  She  had 
passed  no  blood  or  mucus. 

Present  illness:  About  four  years  ago  she  noticed  a  small  lump,  the  size  of  a 
baseball,  situated  below  and  to  the  left  of  the  umbilicus.  The  tumor  increased 
in  size  at  a  uniform  rate,  and  the  patient  thought  she  was  pregnant.  At  the  end 
of  nine  months  the  tumor  reached  above  the  umbilicus.  The  breasts  were  en- 
larged and  contained  colostrum.  The  patient  had  had  no  nausea  or  vomiting. 
Her  menstrual  periods  had  been  regular,  although  she  had  had  a  very  scanty  flow. 
She  was  certain  that  she  had  felt  movements  of  the  child.  About  the  time  that 
labor  should  have  come  on  she  had  bearing-down  pains,  beginning  in  the  evening 
and  lasting  until  early  morning.  The  pains  then  ceased  and  never  returned. 
The  patient  thinks  that  she  has  never  had  any  other  signs  or  symptoms  since  that 
night.  The  breasts  gradually  become  soft  and  dried  up.  The  tumor  seemed  to 
decrease  slightly  in  size.  No  movements  were  felt,  and  the  patient  suffered  no 
discomfort.     She  became  convinced  that  she  had  a  tumor. 

Until  about  a  year  ago  she  could  go  about  her  work  without  difficulty,  but 
then  she  noticed  a  little  soreness,  and  the  tumor  "began  bothering  her.''  In 
the  few  months  previous  to  admission  she  had  felt  an  increase  in  the  amount 
of  soreness.  She  had  had  headaches  at  times,  her  tongue  had  been  coated,  she 
had  frequently  felt  nauseated,  but  had  not  vomited.  After  walking  a  good  deal 
there  was  a  burning  sen.sation  in  the  lower  part  of  the  abdomen,  and  during  the 
last  two  months  the  headaches  had  been  quite  severe.  The  patient  had  to  stop 
work  on  account  of  the  burning  pain  that  would  come  and  go,  but  was  eased  by 
lying  down.  She  slept  well,  but  her  appetite  was  poor,  and  she  said  she  did  not 
gain  in  weight.     There  was  no  pain  or  burning  on  defecation  or  urination. 

Examination. — Dr.  Hutchins,  the  resident  gynecologist,  found  the  patient 
rather  emaciated.     The  abdomen  was  distended  rather  more  on  the  left  than  on 


DIFFERENTIAL    DIAGNOSIS.  475 

the  right  side  by  a  tumor  which  rose  from  the  pelvis  and  reached  4  cm.  above 
the  umbihcus  in  the  median  hne.  The  tumor  felt  cj^stic;  it  was  movable,  dull 
everywhere  on  percussion,  and  no  fluid  wave  was  noted.  On  vaginal  examina- 
tion no  evidence  of  infection  could  ])e  found.  The  cervix  was  firm.  There  was 
slight  bilateral  laceration.  The  uterus  was  in  anteposition,  normal  in  size,  and 
apparently  in  no  way  connected  wdth  the  abdominal  tumor.  Movement  of  the 
tumor  did  not  draw  the  cervix  upward.  Clinically,  the  tumor  was  thought  to 
be  an  ovarian  cyst  or  a  myoma,  but  no  definite  diagnosis  could  be  made. 

Operation.  One  of  us  (CuUen),  after  making  a  long  abdominal  incision,  found 
that  the  abdominal  cavity  was  occupied  by  a  large  ''tumor  of  the  left  ovary,"  to 
which  were  adherent  the  omentum,  the  entire  transverse  colon,  a  portion  of  the 
sigmoid,  and  the  ascending  colon.  The  uterus  was  densely  adherent  on  the 
right  side.  The  omentum  was  tied  and  cut,  a  portion  being  left  attached  to  the 
tumor,  the  proximal  ]X)rtion  being  reflected  backward  with  the  ti-ansverse  colon. 
In  doing  this  the  thin  wall  of  the  tumor  was  ruptured,  and  an  ounce  or  two  of 
thick,  creamy,  yellowish  material  escaped.  This  was  rapidly  sponged  up,  and 
further  escape  controlled  by  pressure  with  gauze.  In  order  to  avoid  infection, 
as  far  as  possible,  the  right  tube,  which  had  been  converted  into  a  pus  sac  and 
was  adherent  to  the  cystic  tumor,  was  liberated.  The  broad  ligament  on  the 
left  side  was  clamped  and  cut,  so  that  the  tumor  could  be  shelled  out  of  the  pelvis 
and  tipped  over  to  the  left  side.  In  this  way  the  grumous  contents  of  the  cyst 
were  prevented  to  a  great  extent  from  escaping  into  the  abdominal  cavity. 
After  the  tumor  was  shelled  out  there  was  a  great  deal  of  bleeding  from  the 
mesocolon.  This  was  checked  as  far  as  possible  by  sutures,  and  the  transverse 
colon  was  then  curved  in  on  itself,  so  that  the  mesocolon  formed  a  funnel.  A 
gauze  drain  was  introduced  into  this  as  it  dropped  down  on  the  pelvic  brim 
and  was  brought  out  through  the  vagina.  In  this  way  we  were  able  to  check 
the  bleeding  almost  completely.  The  abdomen  was  closed  without  di-ainagc 
from  above.  The  patient  made  a  very  satisfactory  recovery  and  was  dis- 
charged October  21,  19()(). 

Path.  No.  10417.  The  specimen  consists  of  an  abdominal  tumor  which  was 
connected  with  the  left  bi'oad  ligament  and  the  left  lube  and  ovary.  It  was 
absolutely  free  from  the  uterus,  which  was  not  removed.  The  specimiMi  in  the 
hardened  state  measures  21  cm.  in  length,  IS  cm.  in  breadth,  and  Ki  cm.  in  its 
anteroposterior  diameter,  .\ttaehed  to  its  right  side  are  a  pus-tube  and  the 
right  ovary.  To  its  left  are  the  lube  and  ovary,  which  are  plastered  down  on 
it.  Covering  almost  the  entire  upper  suiface  of  the  tumor  is  omentum,  wliich  is 
densely  adherent  to  I  he  mass  and  I'ui-nishes  a  lai'ge  pari  of  its  i)h)od-su|)|>ly.  The 
walls  of  this  lunior  \-ary  from  ihe  lhickiies<  i»l'  paper  lo  Iwo  or  ihive  iiiilhnielei-s. 
From  this  tumor  grumous  malerial,  like  I'al  iiii\e<l  uilh  pus.  esc;ipes,  ;itid  at 
several  points  hair  can  be  seen.  When  a  w  indow  is  eul  oul  (  big.  2!l  1 ),  I  he  inlei-ior 
is  found  to  be  (IHed  with  a  felus.  which  is  of  at  least  seven  oi-  eight  months' 
irrowth.     On  account  of  the  disloiled  condition  it  isdillicult  to  get  the  exact  age. 


476 


.MVO.MATA    OF   THK    ITKUCS. 


Foot 


Fig.  294. — Abdomin.^l  Pkegxancy  ok  P'our  Ye.\rs'  Dur.\tio.n. 
Gyn.  No.  13272.  Path.  No.  lOilT.  The  ilhistration  i.s  an  exact  reprothietion  of  the  alxloiniiKil  conteiit.s,  uiid 
ha.s  been  drawn  from  the  specimen.  Attaclied  to  it.s  ri^ht  side  is  a  large  pus-tuhe.  which  is  ilensely  adherent  to 
the  sac.  On  the  left  side  tlie  structures  are  not  clearly  outlined,  as  the  broad  ligament  was  intimately  attaclied  to 
the  pregnant  sac.  Fa.ssing  over  the  anterior  surface  of  the  sac  in  its  upper  portion,  and  considerably  flattened,  is 
the  transverse  colon.  Densely  matted  to  the  .surface  of  the  sac  is  the  omentum.  In  the  upper  part  of  the  sac  a 
window  has  been  cut  out,  and  to  the  left  a  hand,  at  the  top  a  foot,  an<i  lietween  these  two,  and  lying  in  the  vicinity, 
numerous  tufts  of  hair  represented  in  black  may  be  seen.  The  sac  passes  down  and  almost  completely  fills  Douglas' 
pouch.  This  tumor  had  lain  in  the  abdomen  about  four  years.  Apart  from  the  adhesions  to  the  transverse 
colon,  the  intestines  were  perfectly  free. 


DIFFERENTIAL    DIAGNOSIS.  4/< 

Imt  the  sole  of  the  font  iiicasurcs  ().5  cm.  in  Icii.mh  and  looks  matiirc.  The  other 
parts  arc  corrcspondin^iy  lar(2;('.  The  liair  of  the  child  is  black  and  curly.  There 
are  several  points  where  slight  ulceration  of  the  surface  has  taken  place.  These 
correspond  to  the  very  thin  areas  noted  in  the  outer  covering.  The  right  tube, 
which  was  so  firmly  glued  down  that  it  was  thought  necessary  to  remove  it,  in 
the  hardened  state  measures  10  cm.  in  length.  It  is  entirely  covered  with  ad- 
hesions, and  at  its  fimbriated  end  reaches  2.5  cm.  in  diameter.  The  ovary  is 
also  covered  with  adhesions,  but  is  not  enlarged. 

The  left  ovary  is  very  much  flattened  and  covered  with  adhesions.  The  tul)e 
runs  over  into  the  tumor  mass  and  is  lost.  It  is  flattened  out,  and  at  one  point 
measures  8  mm.  in  diameter.  The  placenta  is  attached  to  the  left  side  of  the 
mass. 

Histologic  Examination. — The  sac  inclosing  the  fetus  shows  that  where  the 
omentum  has  becni  adh(>rent  it  has  been  transformed  almost  entirely  into  new 
and  old  connective  tissue;  even  the  outer  adhesions,  which  contain  islands  of 
adipo.se  tissue,  are  for  the  most  part  made  up  of  dense  fibrous  tissue.  Passing 
inward  the  fibrous  tissue  looks  older,  and  then  hyaline  areas  are  seen  which  in 
size  and  form  closely  resemble  placental  villi.  Between  these  are  many  small 
round-cells  and  spindle-cells.  The  inner  portion  is  composed  of  similar  hyaline 
areas,  surrounded  by  a  zone  of  brown  pigment  that  has  evidently  resulted  from 
an  old  hemorrhage.  The  inner  surface  is  lined  with  necrotic  tissue  which  is 
especially  rich  in  canalized  fibrin,  containing  chiefly  polymorphonuclear  leuko- 
cytes. In  no  place  is  there  evidence  of  muscle-fibers,  and  it  looks  as  if  the  case 
was  one  of  an  abdominal  pregnancy  in  which  the  sac,  which  was  partly  supported 
by  the  omentum,  had  gone  on  to  new  connective-tissue  formation. 

Extra-uterine  Pregnancy. 
In  several  instances  we  have  found  it  impossible  to  differentiate  between  an 
adherent  myomatous  uterus  and  a  tubal  pregnancy  that  has  IxM^n  ru|)turetl  for 
several  weeks.  The  ru|)tiii"('d  tube  is  not  onl\'  enlarged  and  suri'ounded  by 
partly  organizing  clots,  but  is  likewise  adherent  to  the  adjacent  strudui'es. 
Where  definite  nniltiple  myomatous  nodules  can  be  fell  on  the  surface  of  the 
uterus,  or  where  a  submucous  myoma  can  be  felt  oi"  has  been  passed,  the  diagnosis 
of  myoma  can  be  made  with  a  fair  degi-ee  of  certainty,  but  it  nnist  be  remembei'ed 
that  tubal  pregnancy  occasi()nail\-  accompanies  a  myomatous  utei-us.  as  noted 
on  p.  .'^42.  The  cessation  of  the  jiericul  for  one  or  two  months,  followed  by  con- 
tinuous bleeding  and  definite  ))ains  on  one  side  of  the  uterus,  is,  of  coui'se. 
strong  i)resumpti\('  exidence  of  tubal  pregnancy. 

A  Ruptured  Cornual  or  Interstitial  Pregnancy  Simulating  a  Myomatous 

Uterus. 

Several  years  ago  Di'.  T.  A.  I!rck.  of  riiiladelphiti.  sent  us  a  specimen  from  a 

patient  that  had  had  a  jielvic  tumor.      It  .somewhat  closely  sinuilati'd  a  myoma. 


478  MYOMATA    OF   THK    UTERUS.. 

Mrs.  G.  ,].,  ajicil  twciity-thrcc,  married  six  years.  Had  one  child  three  years 
ago.  The  hihor  was  normal.  Her  last  period  began  December  22,  1903,  and 
continued  four  days.  On  Ahireh  7.  1904.  she  lifted  a  heavy  wash-boiler  and  was 
taken  with  sudden  abdominal  ])ain,  vomiting,  and  a  bloody  vaginal  discharge. 
She  went  to  bed.  continueil  to  have  intermittent  pain,  and  the  next  day  i)asse(l 
a  clot  as  large  as  a  fist.  Thinking  .she  had  miscarried,  she  remained  in  bed  a 
week  and  then  resumed  her  household  duties.  Two  weeks  later  she  again  had 
much  pain  in  the  hy])ogastrium  and  frequent  vomiting  s]iells.  She  dragged  along 
for  several  weeks  without  medical  attention,  but  was  finally  admitted  to  one  of  the 
Philadelphia  lio.sj)itals  on  June  19,  1904.  The  surgeon,  on  making  an  examina- 
tion, diagnosed  ])regnancy,  with  ])r()bably  a  large  cystic  adherent  ovary.  The 
patient  was  discharged  on  June  22(1.  In  a  .short  time  there  was  recurrence  of 
her  pain  and  vomiting  and  .she  was  admitted  to  another  hospital,  where  .she 
remained  in  bed  four  weeks  but  refused  operation. 

On  August  8,  1904,  she  reentered  the  hospital,  and  at  this  time  had  nuich  pain 
and  frequent  vomiting.  Her  aljdomen  was  distended.  A  hard  irregular  mass 
cotild  l)e  felt  extending  from  the  pelvis  to  a  point  above  the  umbilicus,  ^'aginal 
examination  disclosed  a  soft  cervix.  The  uterus  was  fixed  and  crowded  to  the 
left  side  by  a  mass  occupying  the  right.  The  temperature  was  99°  F.,  the  pulse 
116. 

August  10,  1904;  The  abdomen  was  opened  and  omental  adhesions  to  the 
parietal  ])eritoneum  were  separated.  The  omentum  covered  the  pelvic  organs 
and  was  adherent  to  the  bladder,  the  inner  surface  of  the  broad  ligament,  and 
the  ma.ss  in  Douglas'  cul-de-sac.  After  the  adhesions  had  been  freed,  a  fetus  was 
found  enveloped  in  omentum  and  intestines  to  the  left  of  the  umbilicus.  The 
pelvis  was  now  cleared  of  a  large  amount  of  old  blood-clot,  and  the  placental  sac 
was  found  to  project  from  the  right  cornu  of  the  uterus  (Fig.  295).  Both  tubes 
and  ovaries  were  intact.  The  right  tube  continued  into  the  mass  without  any 
point  of  rupture.  The  ovarian  artery  was  ligated  on  the  pelvic  side  and  cut. 
The  ma.ss  was  then  removed  from  the  uterine  wall,  and  the  raw  area  in  the 
uterus  closed  with  a  continuous  silk  suture.  The  uterus  after  operation  looked 
one-.sided.     The  patient  made  an  uneventful  recovery. 

The  specimen  consists  of  the  right  uterine  cornu,  greatly  distended,  rup- 
tured, and  containing  a  partially  extruded  placenta,  to  which  a  fetus  is  attached. 
Chnging  to  the  side  of  the  cornu  are  the  right  tube  and  ovary.  The  ]wrtion  of 
the  cornu  present  is  8  cm.  in  its  antero))osterior  diameter,  5  cm.  from  right  to 
left,  and  7  cm.  in  length.  The  cornu  has  been  attached  to  the  uterus  ])y  a 
mu.scular  band,  o  cm.  broad  and  2  cm.  in  its  antero))osterior  diameter. 

The  placenta  is  12x7  cm.  and  two-thirds  of  it  has  escaped  from  the  cornu 
through  a  rent  approximately  7  cm.  in  diameter.  The  wall  of  the  cornu  varies 
from  1  to  3  nun.  in  thickness.  The  tube  is  0  cm.  in  length,  and  where  attached 
to  the  cornu  is  exceedingly  small.  It  is  covered  with  a  few  adhesions.  The 
ovary  is  4.5x2.5x2  cm.     It  is  likewise  covered  with  a  few  adhesions.     The 


DIFFERENTIAL   DIAGNOSIS. 


479 


fetus,  doubled  on  itself,  is  13  cm.  in  Icniith,  with  the  tlii^^h  flexed  upon  the 
abdomen  (Fig.  296).  It  is  partially  covered  with  adherent  membrane.  There 
is  malformation  of  the  hand  and  foot  on  the  right  side,  and  also  of  the  left 
foot.     The  left  hand  is  adherent  to  the  membrane  and  is  also  distorted. 

On  histologic  examination  at  the  site  of  amj)utation  a  definite  portion  of  the 
uterine  cavity  is  found.  The  mucosa  here  is  1  nnn.  in  thickness.  The  gland 
elements  are  perfecth'  normal.     The  surrounding  nmscle  shows  a  good  deal  of 


uterine 
att  achmerxt 


Fig.  295.— a  Ruptured  Cornu.'^l  Pregnancy. 
The  right  tube  is  normal.     The  ovary  is  sligiitly  adherent.     The  ri«ht   cortiu   is  considerably  eniarKed.  and 
attached  to  its  inner  aspect  is  a  distorted  fetus.      Its  extremities  have  become  adiierent  to  tiie  t>i>dy,  and  it  is  still 
partially  covered  witli  the  fetal  nieml)ranes.     The  [)lacenta  has  peen  partially  extruded.      (Specimen  sent   by  Dr. 
T.  A.  Erck.  of  Philadeii)hia.,i 

proliferation  of  tiic  ciidothcnuni  of  the  capillaries,  and  the  musclc-ct'lls  them- 
selves are  considerably  swollen.  The  outer  wall  of  the  sac  is  (•omj)osed  of  uterine 
muscle,  and  in  the  outer  muscular  layers  there  is  dilatation  of  the  capillaries, 
with  some  edema  of  the  mu.^cle.  The  sac  contains  a  ( plant  it  y  of  plactMital  tissue. 
That  lying  close  to  the  iim.scle  lias  to  a  great  extent  iiiidergoiie  necrosis.  We  are. 
no  doubt,  dealing  with  a  corniial  |»i-egnaiicv.  Sections  through  the  l'allopi;in 
tube  and  through  the  uterine  horn  show  that  they  are  perfectly  normal. 


480  mvomata  of  thk  iterus. 

Hydatidiform  Mole.* 

The  fulluwing  ease  illustrates  very  well  how  a  hydatid  mole  ^'ivinfi;  I'ise  to  a 
uterine  enlargement  may  he  mistaken  for  a  myoma.  Whenever  a  hydatid 
mole  is  detected,  however,  there  has  been  the  history  of  a  recent  cessation  of 
the  period  and,  on  dilatino;  the  uterus  and  curetting,  the  characteristic  small 
cystic  dilatations  of  the  placental  villi,  as  seen  in  Fig.  297,  at  once  clinch  the 
diagnosis. 

The  j)atient  was  referred  to  me  by  Dr.  ICrnest  Johnston,  of  Berkeley  Springs, 
W.  \'a.,  on  April  S,  1901.  On  admission  to  the  Church  Home  and  Infirmar}^  it 
was  learned  that  five  months  previous  to  the  examination  she  had  missed  her 
period  for  two  months,  and  since  then  there  had  been  a  continuous,  very  dark- 
red  vaginal  discharge.  The  uterus  was  uniformly  enlarged,  and  the  size  of  that 
of  a  three  or  four  months'  pregnancy,  but  the  cervix  was  very  hard  and  the  os 
small.  .Myoma  was  first  .suspected,  but  we  decide(l  to  explore  the  uterine  cavity, 
as  the  tem])orary  cessation  of  menstruation,  followed  by  the  very  dark  discharge, 
was  strongly  suggestive^  of  a  dead  fetus.  On  dilatation  of  the  cervix  and  intro- 
duction of  the  curet  fully  half  a  liter  of  cyst-like  bodies  was  removed.  These 
varied  from  1  mm.  to  2  cm.  or  more  in  diameter.  The  patient  made  a  prompt 
recovery. 

Path.  No.  4S')l.  The  s])ecimen  consists  of  about  half  a  liter  of  small  trans- 
parent cysts,  varying  from  1  mm.  to  2  cm.  in  diameter.  They  have  thin  walls 
and  immediately  remind  one  of  small  .subperitoneal  cysts.  They  are  traversed 
by  a  delicate  network  of  blood-vessels.  The  exact  relation  of  the  majority  of  the 
cysts  cannot  be  determined,  as  they  were  brought  away  with  the  cvn-et.  Here 
and  there,  however,  we  have  been  foi'tunate  enough  to  obtain  large  pieces  of  the 
growth.  At  such  points  we  find  shreds  of  membrane,  and  attached  to  these  by 
delicate  ])edicles,  varying  from  1  mm.  to  2  cm.  in  length,  are  these  small  cysts 
(Fig.  297).  On  further  examination  of  these  cysts  some  of  them  are  found 
to  be  jwar-shaped  instead  of  round.  Accompanying  the  cysts  are  large  and 
small  shreds  of  solid  tissue,  ncj  doubt  portions  of  the  decidua. 

Histologic  Examination. — Sections  from  the  cVvSt  show  that  the  outer  sur- 
faces in  places  have  a  covering  of  syncytium,  veiy  scant  in  amount.  At  most 
])oints,  however,  this  is  wanting.  The  walls  consist  of  spindle-shajM'd  cells, 
and  the  inner  surface  has  clinging  to  it  coagulated  fluid.     There  is  no  layer  of 

*  Thomas  S.  Culleii.  .Johns  Hopkins  Hospital  Hulk-tin,  1902,  vol.  xiii. 


Fig.  233.  —  Ruituke  of  the  Right  (\)knl'  ok  a  IJicornate  Uterus  with  Escape  of  the  F"etus.  (^  nat.  si;!e.) 
The  fetal  membrane  seen  in  Fig.  29.t  lias  been  severeil.  .so  that  the  relations  can  be  more  readily  followed. 
The  cornu  had  partially  ruptured,  and  the  fetus  was  held  in  contact  with  the  uterus  only  by  the  membrane. 
More  than  half  of  the  placenta  has  been  e.xtruded  from  the  ruptured  wall,  and  the  muscle  at  this  point  is 
greatly  thinned  out.  The  fetus  is  macerated.  The  left  leg  is  flexed  and  has  grown  fast  to  the  thigh.  The  left 
arm  is  adherent  to  the  chest,  an<l  has  become  firmly  attached  to  the  membranes.  Tlie  right  arm  and  leg  al.so 
showed  marked  distortion.     (Specimen  sent  by  Dr.  T.  A   Erck.  of  Philadelphia.; 


31 


481 


482 


MYOMATA    OF   THP]    UTERUS. 


cells  liiiiiiii  the  imiiT  surface  of  the  cyst.  These  small  tumors  are  due  to  cystic 
dilatation  of  the  stroma  of  the  villi,  and  hence  are  not  true  cysts.  In  some  places 
typical  villi  are  demonstrable.  Covering  the  outer  surface  of  some  of  the  villi, 
and  in  close  proximity  to  the  cysts,  are  masses  of  cells  somewhat  resembling 

decidual  cells.  They  are.  however,  much  larger  than 
ordinary  decidual  cells.  The  miclei  are  also  larger, 
iri'egular,  and  stain  deeply.  All  gradations,  from  those 
of  normal  size  to  the  large  and  irregular  ones,  can  be 
followed.  While  the  majority  of  these  cells  are  prob- 
ably decidual  in  origin,  some  of  them  are  undoubtedly 
altered  syncytial  cells,  as  the  direct  transition  can  be 
traced. 

The    patient    was    perfectly  well    six  years  after 
ojieration. 


Chorio-epithelioma. 

In  the  following  case*  a  chorio-epithelioma  on 
bimanual  examination  suggested  a  large  myomatous 
uterus,  and  not  until  the  abdomen  was  opened  were 
we  aware  of  the  exact  condition. 

In  all  such  cases,  however,  if  an  accurate  history  is 
obtainable,  it  Mill  be  found  that  the  patient  has  either 
recently  had  a  miscari'riage  or  a  normal  labor,  and  in 
all  these  ca.ses  a  curettage  will  yield  the  characteristic 
growth,  or  at  least  necrotic  material  which  would  at 


Fig.    297. — A    .Small    Fkagment 
OF  A    Hydatidifoum     .Mdlk. 
(§  nat.  size.) 
Path.  No.  4S.51.  The  specimen 


has  been  floated  out  in   water,  in        OUCC  put   the  OpCratOr  OU  llis  gUard. 
ortler  tiiat   the  ramifications  may 


be  followed,  a  corresponds  to  the 
basal  attachment,  and  b  is  a  large 
cystic  dilatation  of  a  villus.  .At 
c  we  have  rows  of  small  oblong 
cysts.  The  main  stem  continues 
downward,  anil  spreads  out  into 
the  conglomerate  mass  of  cysts 
(d),  but  just  above  this  point  it 
gives  off  a  small  stem  of  stroma 
which  ends  in  a  cystic  terminal  (e) 
after  having  given  off  two  terminal 


Gyn.  No.   13204.     Path.  No.   10278. 

Chorio-epithelioma  with  the  uterus 
the  s  i  z  e  o  f  t  li  a  t  o  f  a  five  m  o  n  t  h  s  ' 
j)  r  e  g  n  a  n  c  y  ;  h  y  s  t  e  r  e  c  t  o  m  y  ;  t  e  m  p  o  - 
r  a  r  y    r  e  c  o  v  e  r  y  . 

The  patient  was   admitted   August   31,  and    was 
twigs  (e')  with  cystic  ends.    At  f     discharged  September   2.").    190(3.     On   examination, 

is  a  cystic  dilatation   in   the  con-        t^       t-«       i  r  i     i  i     i  i      ^    i-    ^         i      i 

tinuityof  a  villus, a  short  distance     Di'.  Kushmore  touiid  thealxlomen  somewhat  distemled 

further  on  followed  by  the  termi-       ^      ^  ^j.,^j   „j,^^^_    ^^.l,;,.],    ,.,,^,,  ,,^u    ,,j'   jj^^.  pc\y\H  and    CX- 
nal    bunch    of    cysts,    g.       (After  •  ... 

Thomas  s.  Cuiien.)  tended  as  high  as  the  umbilicus,  rather  more  pronii- 

neiilly  on  the  left  than  on  the  right  side.  The  mass 
was  .slightly  moval)le,  and  not  tender,  e\cej)t  just  above  Poupart's  ligament  on 
the  left  .side.      It  was  regular  in  outline,  and  on  deep  inspiration  its  ui)per  border 

*  Thomas  S.  Cullcn,  .\  ."Series  of  Iiitcrcstinj;  (lyiiecolo.iiic  ami  Olj.'^ti'trio  Ca.ses,  .Jour.  A.  M.  A., 
Mav  4,  1907,  vol.  xlviii. 


DIFFER KXTIAL    DIAGNOSIS.  483 

was  obliterated  by  the  suiToimding  intestines.  The  vaginal  outlet  was  moder- 
ately relaxed,  the  cervix  was  high  in  the  vaginal  vault,  lying  far  back  and  pointing 
downward.  The  cei-vical  lips  were  not  hypertrophied ;  the  os  was  slightly 
patulous.  There  was  no  iiuluration  suggestive  of  a  new-growth.  The  mass  in 
the  pelvis  was  uniformly  fixed.  On  examination  under  ether  the  tumor  was 
freely  movable,  but  suggested  a  myoma  about  six  inches  in  diametei'.  with  a 
cystic  mass  on  the  left.     The  l)reasts  contained  colostrum. 

On  exposure  of  the  enlarged  uterus  the  appearance  suggested  pregnancy  very 
.stronglv.  The  ves.sels  were  much  dilated.  No  definite  nodules  could  be  made 
out  in  the  fundus,  but  on  the  i)Osterior  surface  was  a  slight  prominence,  with  a 
curious  yellowish  discoloration  of  the  tissue  beneath,  and  there  were  numerous 
dilated  ve.s.sels  suggestive  of  a  malignant  new-growth.  As  a  definite  diagno.sis 
could  not  be  made  from  palpation,  we  decided  to  incise  the  uterus  over  the 
prominence,  at  the  same  time  carefully  walling  it  off  so  that  the  general  cavity 
would  be  jjrotected.  On  incision,  a  vascular  new-gi-owth  was  immediately  seen. 
This  had  a  spongy  appearance,  and  immediately  suggested  a  malignant  growth, 
differing  entirely  from  carcinoma  and  sarcoma.  Dr.  Cuthbert  Lockyer,  of 
London,  Eng.,  a  man  who  has  contributed  largely  to  our  knowledge  of  this  sub- 
ject, was  with  me  (Cullen)  at  the  time,  and  corroborated  the  diagnosis  of  chorio- 
ei)ithelioma.  The  incision  was  immediately  closed,  and  the  uterus  removed. 
The  liver  was  carefully  examined  for  metastases,  but  none  could  be  detected. 

In  this  case  there  was  no  positive  history  of  a  recent  miscarriage,  although 
the  possibility  cannot  be  excluded.  The  contour  of  the  uterus  on  pelvic  ex- 
amination strongly  suggested  a  myomatous  uterus,  and  with  the  abdomen 
opened  it  was  impossible  for  one  to  exclude  pregnancy. 

Path.  No.  10278.  The  specimen  consists  of  a  greatly  and  uniformly  en- 
larged uterus,  measuring  20  cm.  in  length,  13  cm.  in  breadth,  and  12  ciii.  in 
thickness.  The  anterior  surface  is  smooth  and  glistening;  the  jjoslci-ior  is 
covered  with  many  adhesions,  thin  and  fan-like.  Attacheil  neai'  the  lel't  rdi'nu 
is  a  tag  of  onuMituni.  ( )n  set-tioii,  the  utei'ine  (-n'ity  is  found  to  be  1.")..")  cm.  in 
length.  The  uterine  walls  wiry  from  3  to  (>  cm.  in  thickness.  The  outer  jiort  ion 
of  the  wall  consist-^  of  inu-;cle,  \-ai'}'ing  from  1  to  I ..")  cm.  in  thickness.  I.ininu-the 
entire  uterine  cavity  is  a  s])ongv,  j)oi-ous  growth  ( l"'ig.  21)S).  The  utei-ine  nuicosa  as 
such  is  not  I'ccognized,  but  is  repi'esented  by  hills  and  hollows.  The  j)i-ojections 
into  the  ca\'ity  are  dome-shapeil,  and  \ary  fi'om  ()..')  to  2  cm.  in  depth.  I  Jereand 
there  on  the  suii'ace  are  cyst-like  de|)i-e-<sions,  with  nai'i'owcil  bands  of  tissue 
sti'etching  from  side  to  side.  Tliei'e  are  also  innnerou<  caxcnious  spaces,  bi'idged 
oN'er  by  bands  of  the  growth.  This  gi'dwih  inx'oKcs  the  entire  uterine  wall, 
both  antefiofly  and  posteiiorly.  The  ureal  thickness  in  the  wall  is  due  to  the 
j)resence  of  the  gi'owt  h,  which  \aiie<  fi'oni  1  to  (1  cm.  in  I  hickness.  .\t  the  fundus 
it  extends  almost  to  the  peritoneal  i-o\-eiing.  The  grow  ih  in  no  way  resembles 
either  a  carcinoma  oi"  a  sai'coma.     ( )ne  is  instant  \v  I'emiiiileil  of  the  irrowth  that 


484 


.MYOMATA    OF   THK    ITEUrS. 


occasionally  occurs  after  a   miscarriage.     The  cervix  is  somewhat    flattened, 
is  6  cm.  in  breadth,  and  its  lips  ajjpear  to  be  normal. 


Fig.  298. — Chorio-epithelioma.  (5  nat.  size.) 
Gyn.  No.  13204.  Path.  No.  10278.  The  specimen  consists  of  a  uniformly  en  arged  uterus.  The  cervix  is 
normal;  the  body  is  as  large  as  that  of  a  five  months'  pregnancy.  Occupying  tiie  entire  body  of  the  uterus  is  a 
new-growth  with  many  depressions  and  cystic  spaces  extending  into  the  wall.  The  growth  itself  presents  a  pecu- 
liar porous  appearance  (b),  and  the  finger-like  processes  so  characteristic  of  carcinoma  are  absent.  In  the  lower 
part  of  the  uterus  the  outer  muscular  walls  are  still  clearly  seen,  but  in  the  upper  part  of  the  cavity  the  growth 
has  extended  almost  to  the  peritoneal  surface.  The  growth  coidd  hardly  be  mistaken  for  anytliing  else.  It  is 
remarkable  to  see  so  uniform  an  involvement  of  the  entire  uterine  wall,  a  indicates  clearly  the  sharp  line  of 
demarcation  between  the  malignant  growth  and  the  outer  musctdar  covering. 


Histologic  examination  sliows  the  gi'owth  to  be  a  tyj)i('al  chorio-cpithelioma. 
After  some  months  the  i)atieiit  commenced  to  lose  ground,  and  soon  died  with 
metastases. 


DIFFERENTIAL    DIAGNOSIS.  485 

Enlargement  of  the  Uterus  Due  to  a  Retained  Menstrual  Flow. 

In  190()  we^  received  word  from  one  of  the  most,  cai-eful  practitioners  in  the 
State  saying  that  he  was  going  to  send  a  patient  with  a  uniformly  enlarged  and 
globular  uterus  for  operation,  and  that  the  enlargement  was  apparently  caused 
by  a  nwoma.  During  the  long  railroad  ride  the  patient  lost  nnich  blood,  and 
when  one  of  us  examined  her  at  the  hospital  the  uterus  showed  little  enlarge- 
ment. From  the  history,  it  will  be  seen  that  as  the  result  of  an  endometritis 
the  vaginal  walls  had  become  irritated  and  later  agglutinated.  Successive 
menstrual  flows  had  thus  been  retained,  and  the  uterus  had  become  distended. 
The  jolting  over  a  poorly  ])allastcd  railroad  had  been  sufficient  to  partially 
separate  the  adherent  vaginal  walls;  the  fluid  contained  in  the  upper  part  of  the 
vagina  and  distending  the  uterus  had  escaped,  and  the  suj^posed  uterine  tumor 
disappeared. 

P.,  admitted  to  the  Church  Home  and  Infirmary  June  17,  1906.  The  patient 
was  fifty  years  of  age.  For  several  months  she  had  had  no  periods,  but  recently 
there  had  been  an  excessive  amount  of  pain  in  the  lower  abflomen.  The  en- 
largement was  apparently  due  to  a  myoma.  Her  i^hysician  found  a  glo])ular 
and  enlarged  uterus.  During  a  long  railroad  journey  she  had  had  a  profuse 
bloody  discharge,  and  the  abdominal  pain  hatl  to  a  great  extent  disappeared. 
We  examined  the  patient  under  ether,  and  found  the  vagina  closed  half-way  up, 
but  there  was  just  a  small  opening.  This  could  readily  be  dilated  with  the  finger, 
and  there  was  an  immediate  escape  of  old  blood,  rojiy  in  character.  The  cer\-ix 
was  considerably  dilated.  Pressure  on  the  uterus  increased  the  flow.  We 
stretched  the  cervix  and  curetted  the  uterus,  but  obtained  little  mucosa. 

On  histologic  examination  of  the  mucosa  we  found  that  it  was  the  seat  of 
acute  inflammation.  In  this  case  there  had  been  an  acute  endometritis.  The 
vaginal  surfaces  had  l)ecome  glued  together,  and  complete  occlusion  had  taken 
place.  There  hud  l)een  an  accumulation  of  secretion  in  the  uterine  cavity, 
gi\'ing  rise  to  the  supposedly  globulai'  myomatous  uterus,  and  at  the  same  time 
causing  a  great  deal  of  disconifoi't  from  the  distent  ion. 

Carcinoma  of  the  Uterus. 

Hcfoi'c  considci'ing  the  (Hfficulties  in  diagnosing  carcinoma  of  the  uterus  from 
myoma,  it  may  be  well  to  glance  at  Chapter  X\'l,  ]>.  274,  in  whicli  many  cases 
of  carcinoma  of  tiie  body  associatcnl  with  lUeiine  myoma  are  described. 

When  the  carcinoma  commences  in  the  vaginal  portion  of  the  cer\i\,  the 
dilTerential  diagnosis  between  a  malignant  gi-o\\lli  and  a  niyonia  is  usuall\"  easy, 
but  in  some  cases,  when  a  sloughing  sul)iiiuco\is  luxdnia  pi'ot  rudes  Irom  the 
cervix  aii<l  ])aitiall\'  (ills  the  \agina,  it  may  he  mistaken  for  a  cauliflower-like 
carcinomatous  mass.  The  |)e(licle  of  the  myoma  is  usually  attached  high  up 
in  the  cer\'ical  canal  oi-  in  the  IxkIv  of  the  uterus,  and  the  linger  can  lie  cari'ied 
around  it  on  all  sides.      When  carcinoma  of  the  cer\i\  is  pi'esent,  the  gi'owth 


486 


.MVo.MATA    OF    TlIK    ITKRUS. 


*  ^.  /     '       I 


Fig.  299. — C.\rci.som.\  of  the  Ckkvi.k  .\sd  Lower  P.-irt  of  the  Hodv  ok  the  Uterus  Ci.inicai.i.v  .Sicckstixg 

A  .Myo.m.\tous  Organ.  (Nat.  size.) 
Gyn.  No.  10490.  Path.  No.  6727.  The  uterus  was  globular  and  about  the  size  of  that  of  a  four  months' 
pregnancy.  The  vaginal  portion  of  the  cervi.x  was  normal.  The  greater  part  of  the  cervix  and  tlie  lower  portion  of 
the  body  of  the  uterus  were  occupied  by  carcinomatous  tissue.  Mas.ses  of  it  are  seen  projecting  into  the  uterine 
cavity  at  a,  a,  a.  The  cervical  canal  had  been  blocked,  and  the  body  of  the  uterus  had  become  much  distended  and 
was  filled  with  pus.  The  mucosa  has  been  replaced  by  granulation  tissue,  as  recognized  by  the  undulating  surface 
so  often  noted  where  a  suppurating  membrane  exists.  From  the  normal  appearance  of  the  cervix,  the  uniform 
contour  of  the  body  and  the  firmness  of  the  tissue,  myoma  was  naturally  diagnosed.  Had  carcinoma  l)een  sus- 
pectetl,  curettage  would  have  at  once  established  the  true  diagnosis. 


])IFFf:rextial  diagxosis. 


487 


springs  from  the  ccrN-ix  ilscif,  is  cxcccdingiy  triahlc,  ami  l)U'C(ls  \-cr\-  much  mure 
freely  on  manipulation  than  the  suhnnieous  myoma.  If  the  diagnosis  cannot 
be  established,  histologic  examination  of  the  tissue  may  at  once  afford  the 
proper  diagnosis. 

If  the  carcinoma  be  far  up  in  the  cervical  canal  or  in  the  body  of  the  uterus, 
con.siderable  confusion  may  arise. 

The  following  cases  are  very  good  examples  of  the  difliculty  in  deciding  be- 
tween mvomata  and  carcinoma  of  the  uterus. 


''    V    L    X 


Fig.  300. — A  Submucous  Myo.ma  Clinic.\lly  Suggesting  Carcinoma  of  thk  Cervix,  d",  luit.  size.) 
Gyn.  No.  1.3498.  Path.  No.  10776.  The  clinical  hi.story  stroiijtly  suftKe-sted  carcinoma  of  tlie  uteiu.s.  On 
examination  the  vaginal  portion  of  tiie  cervix  was  found  to  be  normal,  hut  the  greater  part  of  tiie  cer\ix  was  much 
enlarned  an<l  hard.  So  sure  was  the  operator  of  tiie  malignancy  of  tlie  growtii  that  he  did  a  complete  hysterec- 
tomy. In  the  illustration  the  small  vaginal  portion  of  the  cervix  is  intact.  The  uterine  cavity  has  heen  opened 
and  unfoldccl.  With  the  uterus  closed,  points  a  and  a'  would  come  together.  The  great  harilne.ss  in  the  lower  part 
of  the  uterus  was  due  to  the  peduticulated  submucous  myoma  b.  Thi.s  also  gave  rise  to  the  suspicious  discharge, 
c  is  a  small  polyp.     Scattered  throughout  the  uterine  wall.s  are  a  few  small  ititerstitial  myt)mata. 


The  uterus  in  Ciyn.  No.  1()4()()  (Path.  No.  ()727)  formed  a  glol)ular  ma.ss, 
about  the  size  of  that  of  a  four  months"  pregnancy.  .Myoma  was  diagiutscd. 
( )n  opening  the  su|)|)ose(||y  myomatous  utenis.  the  eerx'ix  and  lowci'  pai't  nf  the 
hinW  were  found  (illeil  with  carciiionialous  tissue  (  f'ig.  2!)'.));  the  cax'ity  of  the 
uterus  was  full  of  jtiis.  .\  glance  at  the  cei-\-i\  will  show  that  on  \'aginal  ex- 
amination it  a|)|)eai'ed  pei'jeelly  iiomial.  ('ui'eltage  in  this  case  would  ha\'e 
cleared  uj)  I  he  diiigiiosis  at  (ince,  but ,  a^  a  rule,  w  hei'e  t  he  condil  i( )n  is  sup])osedl^• 
one  of  simple  myoma,  one  hardly  deems  it  wisetocuret    unless  some  important 


488 


MVOMATA    OF   THK    rTKRUS. 


"^f/1 


iiit'urinatiuii  scciiis  to  be  proiiiised.     Wht'iicver  carciiioiiui  is  .suspected,  scrapings 
should  by  all  means  be  examined  prior  to  attempting  the  hysterectomy. 

On  the  other  hand,  a  myoma  may  simulate  a  carcinoma,  as  was  noted  in 
Case  13498  (Fig.  300).  The  operator  found  a  .small  external  os  and  an  apparently 
much  enlarged  and  densely  hard  cemx.  So  sure  was  he  that  the  growth  was 
carcinomatous,  that  he  made  a  rather  extensiveand  complete ahdomiiial  hv.ster- 
ectomy.  The  enlargement  and  denseness  of  the  cervix  were  due  to  a  .subnuicous 
and  pedunculated  myoma  (6). 

In  Gyn.  No.  10440  the  patient  was  exceedingly  stout,  and   had  a   relatively 

small  uterus.  One  of  us,*  on 
thorough  bimanual  examination, 
clearly  felt  nodules  on  the  surface 
of  the  uterus,  and  accordingly 
made  a  diagno.sis  of  nmltiple  myo- 
mata.  A  glance  at  the  accom- 
panying history  of  the  case  will 
show  that  the  gi-owth  was  prim- 
arily a  carcinoma  of  the  body, 
with  extension  by  continuity  to 
the  peritoneal  surface. 

Gyn.  No.  10440  ;  Path.  No.  6644. 
Diagnosis;  Myoma- 
tous uterus.  Act  u  a  1 
condition  :  a  d  e  n  o  c  a  r  - 
c  i  n  o  ni  a  of  the  I)  o  d  y  o  f 
the  uterus,  ^^•  i  t  h  s  e  c  - 
o  n  d  a  r  y  s  u  b  p  e  r  i  t  o  n  e  a  1 
nodules     (Fig.     301). 

^1.  C,  aged  fifty-eight,  white. 
Admitted  April  22,   1903.      The 
])atient    has  had    three   children. 
The  menses  stoj)ped  at   forty-nine.     Four  years  ago  uterine  hemorrhages  com- 
menced and  lasted  several  months.     Since  then  they  have  been  irregular.     There 
is  a  coiitimial  leukori'heal  discharge,  with  .some  odor. 

On  vaginal  examination  we  found  the  uterus  about  twice  its  natural  size. 
Scattered  over  its  surfac(>  were  numerous  nodules.  As  the  patient  was  in  good 
condition  and  had  a  nodular  uterus,  which  in  general  contour  closely  resembled 
a  myomatous  uterus,  we  made  a  diagnosis  of  myoma  (Fig.  301),  especially  as  the 
hemorrhages  could  readily  be  accounted  for  by  the  presence  of  myomata  and 
the  vaginal  discharge  was  but  slightly  offensive. 

*  Thomas  S.  CXillen,  A  Series  of  Mistaken  Gynecologic  Diagnoses,  J.  A.  M.  A.,  November 
19,  1904. 


Fig.  301.— Adenocarcinoma  of  the  Body  of  the  Uterus 
WITH  Subperitoneal  Nodules.  (|  nat.  size.) 
Gyn.  No.  10440.  Path.  No.  6644.  The  specimen  is  viewed 
from  the  front.  The  right  round  ligament  is  drawn  upward  by 
a  cancerous  nodule  situated  at  its  junction  with  the  uterus. 
Scattered  over  the  surface  of  the  uterus  are  cancerous  nodules, 
varying  from  a  few  millimeters  to  2  cm.  or  more  in  diameter. 
The  insertion  of  the  left  round  ligament  is  at  a  much  lower 
level  than  is  that  of  the  right.  The  general  contour  of  the  en- 
larged and  nodular  uterus  closely  resembles  that  of  a  myoma- 
tous organ.     (.After  Thomas  S.  Cullen.) 


DIFFERENTIAL    DIAGNOSIS.  489 

At  operation  we  found  the  uterus  as  I  have  deseribed  it,  but  the  supposedly 
myomatous  nodules  represented  points  at  which  the  cancer  of  the  body  of  the 
uterus  had  extended  to  the  peritoneal  surface.  They  were  raised  nodules  beneath 
the  surface,  and  at  several  points  had  become  attached  to  the  intestines.  Com- 
plete hy.sterectomy  was  performed.  The  patient  made  a  good  recovery,  and  was 
in  perfect  condition  five  years  later.  In  this  case  curettage,  even  without  a 
microscopic  examination,  would  have  been  sufficient  to  establish  the  diagnosis. 

In  Path.  No.  4479  (Fig.  180,  p.  286)  we  did  a  supravaginal  hysteromyomec- 
toniy.  Myomatous  nodules  were  scattered  over  the  surface  of  the  uterus,  and 
the  entire  growth  seemed  to  be  myomatous  in  character.  On  examination  of  the 
specimen  in  the  laboratory  the  greater  part  of  the  enlargement  was  found  to  l)e 
due  to  a  carcmoma  of  the  body  of  the  uterus.  If  the  operator,  with  the  alxlo- 
men  open,  sometimes  fails  to  differentiate  between  carcinoma  and  myoma,  there 
is  certainly  abundant  excuse  for  the  general  practitioner,  who  has  to  rely  on 
the  bimanual  examination. 

In  Case  3693  we  have  another  example  of  the  difficulties  in  deciding  between 
myoma  and  carcinoma.  On  referring  to  Fig.  302  it  will  be  noted  that  the  uterus 
is  nodular  and  several  times  its  natural  size.  The  cervix  is  enlarged,  but  intact; 
the  cavity  is  lined  with  nodular  masses  that  bear  some  resemblance  to  the 
myomata  which  sometimes  pave  the  uterine  cavity.  Further,  it  will  be  noted 
that  although  the  patient  had  had  a  profuse  leukorrheal  discharge,  there  was  no 
hemorrhage.  Scrai)ings  in  such  a  case  would  at  once  yield  carcinomatous 
tissue. 

Gyn.  No.  3693  ;   Path.  No.  828. 

A  n  II  n  u  s  u  a  1  c  a  r  c  i  n  o  m  a  t  o  u  s  uterus,  bearing  c  0  n  - 
side  r  a  b  1  e  r  e  s  e  m  b  1  a  n  c  e  t  0  a  m  y  o  m  a  t  o  u  s  organ*  (Fig. 
30  2). 

N.  G.,  aged  seventy-six,  white.  Admitted  July  30;  {lischarg(Hl  September 
8,  1895.  The  menses  ceased  twenty-five  years  ago.  The  patient  has  always 
been  healthy.  One  grandfather  died  of  cancel',  and  several  i-clatives  of  tuber- 
culosis. For  the  last  year  she  has  had  a  profu.se  bloody  vaginal  discharge,  and 
has  experienced  sharp  shooting  })ains  all  through  the  abdomen.  Vov  the  relict  ot 
these  during  the  last  six  months  she  has  taken  a  good  deal  of  opium.  At  no  time 
has  she  had  uterine  lieinonliages.  Her  genei'al  condition  is  \hh)v:  she  eats  x-eiy 
little;  her  tongue  is  red  and  fissured;  the  bowels  are  constii)ated.  On  vaginal 
examination  tiie  cervix  is  found  to  be  intact,  lait  enlarged:  the  uteinis  is  about 
the  size  of  that  of  a  three  months"  ])regnanc}-,  and  somewhat  nodulni'.  A  com- 
plete hysterectomy  was  done. 

Path.  No.  S'JS.  The  specimen  consists  of  the  utci-usand  appendages  intact. 
J^oth  anteriorly  and  postci-ioily  the  oi'gan  is  smooth  ;md  glistening.      Projecting 

*Thiscasc  was  nimitcii  in  lull  in  C'oiiliiliuliniis  to  llic  Sc-ifiict' of  .Mi'diciiic,  l)y  the  Pupils  of 
Wiliiiiiii  H.  Welch,  KtOO,  p.'^e   101. 


490 


.MVO.MATA    OF    THK    UTERUS. 


from  the  anterior  surface,  about  2.5  cm.  from  the  fundus,  are  two  sul)|)eritoneal 
lujilulcs.  These  are  irreguhir  in  contour,  whitish  yellow,  and  covered  with 
peritoneuni  (Fig:.  302).  Tliey  do  not  project  more  than  2  mm.  from  the  .surface. 
Just  posterior  to  the  i-i^iht  cormi  is  a  similar  elevation,  2.5  cm.  in  diameter. 


Fig.  302.— a  Rare  Form  of  .\de.noc.^rcinoma  of  the  Uterus.  (Nat.  size.) 
Path.  Xo.  828.  The  uterus  is  nearly  three  times  its  natural  size;  it  presents  a  nodular  surface,  as  noted  at  a 
and  a'.  The  cervix  is  greatiy  thickened,  but  the  vaginal  portion  and  the  external  os  are  still  intact.  The  organ, 
from  the  external  os  to  the  fundus,  is  occupied  hy  a  new-growth  which  entirely  obliterates  the  normal  landmarks. 
The  uterine  cavity  is  linetl  with  large  and  small  dome-like  mas.ses.  consisting  almost  entirely  of  necrotic  tissue. 
The  new-growth  has  invailed  the  cervix  and  body  unifonnly,  extending  in  most  places  to  within  5  mm.  of  the 
peritoneal  covering,  and  at  a  and  a'  reaching  the  outer  surface.  The  growth  is  whitish  in  color,  very  friable,  and 
stands  out  in  sharp  contrast  to  the  uterine  muscle.     (After  Thomas  S.  Culien.) 


On  palj)ation  the  uterus  seems  to  contain  many  areas  which  present  a  stony 
hardness.  The  cervix  is  'A.o  cm.  in  diameter,  and  is  intact.  It  feels  somewhat 
soft  to  the  touch,  but  at  the  same  time  one  obtains  the  im])ressi()n  that  there  are 
deeper  areas  which  are  vei'v  dense. 


DIFFERENTIAL    DIAGXOSIS.  401 

Oil  section,  the  ('crvical  niucosa  presents  the  usual  ap))earaiice  for  a  distance 
of  5  mm.,  hut  aboNc  this  point  it  is  ])ractically  impossible  to  distinguish  bctwet^n 
the  cavity  of  the  cervix  and  that  of  the  body,  both  being  of  equal  breadth.  The 
combined  cavity  is  10  cm.  in  length.  Almost  from  the  external  os  to  the  fundus 
the  walls  are  composed  of  necrotic-like  tissue,  which  is  gathered  up  into  large 
and  small  dome-like  masses.  Covering  the  inner  surface  is  a  dirty  greenish 
or  reddish  material.  The  uterine  walls  from  cervix  to  fundus  have  been  in- 
vaded by  a  new-growth  which  penetrates  the  niusch^  to  within  from  S  to  2  mm. 
of  the  surface;  the  wall  has  ))een  invaded  throughout  its  entire  thickness,  these 
areas  being  nothing  more  than  a  continuation  of  the  growth. 

The  cervix  and  body  are  almost  uniformly  im])licated,  although  the  former, 
perhaps,  has  suffered  a  little  more  extensively. 

Histologic  examination  shows  this  growth  to  be  a  carcinoma  of  a  most  un- 
usual type.  It  is  described  and  pictured  in  detail  in  ''Cancer  of  the  Uterus," 
p.  588.' 

Histologic  Changes  in  Myoma  suggesting  Carcinoma. 
Sarcomatous  changes  in  myomata  are  by  no  means  rare.     (See  Chapter  XI\', 
p.  169.)     For  the  primary  development  of  a  carcinoma  in  a  myoma  it  is  absolutely 


Fic.  30:5. — A  l'i;ci!i,i\i{  Arraxgemext  of  Mu.scle-fiberh  Suocsestive  m  Caui  inom  \.      (  \   1 10  iliam.  < 
Gyii.  No.  12.j'.)l.      I'alli.  No.  9349.     The  specimen  i.s  from  the  center  of  ii  .siil>nuu'inis  ni.Nonia.     The  pah'  areas 
are  due  to  hyahne  ilejjieneration.     Tlie  remaining  muscle-fibers  are  urrunKcd  in  struiiclit,  irrenular  or  curved  groups, 
as  indicated  l)y  a.     .M  1)  are  capillaries,  .some  of  Ihein  surroutuled  l>y  a  zone  of  hyaline.     The  picture  at  first  sug- 
gests carcinoma,  Imt  all  the  niuscli'-niicli'i  arc  of  tlio  usual  si/.c  and  there  is  no  epithelium. 


492 


MVO.MATA    OF    THK    UTERUS. 


necessary  to  have  had  })n'(''xistinti:  <2;lan(ls,  and  these  are  found  only  in  an  adeno- 
niyonia.  Nevertheless,  we  may  hav(»  the  niiisele-fibers  arranged  in  such  a  way 
that  they  closely  resemble  alveoli.  In  Case  12591,  for  example,  a  submucous 
myoma,  6  cm.  in  diameter,  was  removed  through  the  vagina.  Histologically 
(Path.  No.  9349),  the  surface  of  the  myoma  was  covered  with  squamous  epi- 
thelium, and  the  muscular  tissue  had  undergone  marked  hyaline  degeneration 
and  liquefaction.  The  remaining  nuisclc-hbers  were  arranged  in  single,  straight 
or  curved,  rows  (Fig.  303)  and  at  first  sight  strongly  suggestetl  carcinoma,  but 
on  careful  study  of  the  nuiscle  nuclei  they  were  found  to  be  of  a  uniform  size, 
and  there  was  no  doubt  that  the  u'rowth  was  benign. 


Sarcoma  of  the  Uterus. 
Sarcoma  of  the  uterus,  in  our  experience,  has  in  the  majority  of  cases  devel- 
oped in  or  been  associated  with  uterine  myomata.     (See  Chapter  XR',  p.  169.) 
In  such  cases  the  only  clinical  clue  to  the  malignant  growth  is  the  fact  that  the 
tumor  has  of  late  grown  very  rapidly. 


Fii;.  304. — Sahcoma  ok  the  Body  of  the  Uterus.     {\  nat.  size.) 
Path.  10494.     The  body  of  the  uterus  is  irregularly  enlarged,  and  at  a  is  the  volcanic  welling-out  of  a  growth 
which  occupies  the  interior  of  the  organ.     The  cervix  and  appendages  are  normal.     For  the  appearance  of  the 
growth  on  section  see  Fig.  305. 


When  the  growth  from  the  beginning  is  a  .sarcoma,  it  may  imj)licate  the  uterus 
uniformly,  or  produce  numerous  nodular  elevations.  If  the  major  {jortion  of  the 
tumor  is  subperitoneal,  it  may  possibly  be  I'ecognized  by  the  soft  feel;  if  sub- 
mucous, portions  can  be  curetted  away  and  the  diagnosis  established. 


DIFFERENTIAL    DIAGNOSIS. 


493 


In  Fig.  304  we  have  an  example  of  an  enlargcnl  uterus  which,  from  its  contour, 
suggested  an  irregular 
myomatous  growth. 
Dr.  James  Bosley,  under 
whose  care  the  patient 
had  come,  had,  how- 
ever, recognized  the 
malignant  character  of 
the  growth  from  scraj)- 
ings  obtained  a  few 
weeks  before.  In  Fig. 
305  we  see  the  appear- 
ance of  the  sarcoma  on 
section.  The  cervix  is 
normal,  and  would  yield 
no  clue  on  vaginal  ex- 
amination. The  ]:)ody 
of  the  uterus  is  occu- 
pied by  a  homogeneous 
growth  which  has  ex- 
tended to  the  peritoneal 
surface  at  several  points. 
It  shows  considerable 
hemorrhage  and  degen- 
eration in  the  area  in- 
dicated by  b. 

The  diagnosis  be- 
tween sarcoma  and  my- 
oma is  in  some  cases 
absolutely  impossible 
prior  to  operation. 


Fibroma  of  the  Ovary. 
The  diagnosis  be- 
tween filiroina  of  the 
ovary  and  myoma  ot 
the  uterus  may  be  faii-ly 
easy,  provided  it  is  pos- 
sible to  outline  a  per- 
fectly normal  uterus.  If,  on  the  other  hand,  the  utems  contains  inyomata.  the 
differentiation  between  the  solid  ovarian  tunioi-  and  the  tnyoinata  is  well-nigh 
imjjossible.     The  following  cases  illustrate  tins  dilllcullv: 


I     X 

Fig.  305. — Sarcoma  ok  tin-;  Body  oi-  tiik  riKitus.  (.Nut.  size.) 
Path.  No.  10494.  For  (lie  Keiieral  appeiiriiiice  of  the  uterus  see  Fig. 
301.  A  few  cervical  glands  are  ililateil.  otherwi.se  (he  cervix  is  normal,  a 
is  the  (listorteil  u(erine  cavi(y.  Occup.virig  the  fundus  is  a  homogeneous 
growth  siiowing  little  structure.  .\t  1)  it  is  hemorrhagic  and  is  disintegrating. 
At  (•  the  growih  forms  a  iiodiil.ir  pnijcctidii  frnin  llic  peritoneal  surface.  The 
p(islcipci-ali\i'  hisldiN-  iriilicali'il  u  iili-spiiM,!  I\  inph:il  ic  iin'olvement  in  a  few 
months. 


494 


MYn.MATA    OF    Tlii:    ITKHUS. 


Gyn.  No.  9090.     Path.  No.  5247. 
F  i  1)  r  o  111  a    o  f    t  h  c    o  v  a  r  y  ;    s  111  all    uteri  11  c    111  y  o  m  a  t  a  . 
C.  C,  H'^inl  sixty-two,  white.     Admitted  Sei)teinl)ei-  27;  discharged  October 
20,  lllOl.      I'illiiiu'  the  lower  al)(loiiieii.  and  exteiidiiiii  almost  to  the  umbilicus, 


Fig.  306. — Fibrom.v  ok  the  Ov.\ry.      (i  Nat.  size.) 
Gyn.  No.  9090.      Path.  No.  .5247.     The  irregular  Klobular  mass  measured  12  x  14  .\  16  cm.,  and  was  wliitish  in 
appearance.     KamifyinK  over  its  surface  were  numerous  blood-vessels.     At  several  points  were  small  subperitoneal 
cysts.     A  colony  of  them  is  seen  at  a.     When  lyinK  on  the  table,  the  tumor  bore  a  striking  resemblance  to  a  sub- 
peritoneal myoma.     The  pedicle  was  .")  mm.  broad  and  l.o  cm.  long. 

was  an  irregular  and  freely  mo\-al)le  nodular  ma.ss.     The  ceiA-ix  was  normal, 
but  the  bod}'  of  the  uterus  could  not  be  ()Utliiie(l. 

On  section  of  the  alxlomen  a  fibroma  of  the  ovary,  12  x  14  x  l()cm.,  was  found 
fFig.  306).  Three  small  subj)eritoneal  myomata,  not  over  1  cm.  in  diameter, 
and  another  2  cm.  in  diameter  and  i)edunculate(l.  were  removed  from  the  uterus 
and  the  ))atient  made  a  good  recovery. 


DIFFERENTIAL    DIAtiXOSIS.  495 

A  glance  at  Fig.  3UG  will  show  that  the  tibruiiui  of  the  ovary  bore  a  striking 
resemblance  to  a  myoma,  and  the  further  fact  that  the  uterus  contained  small 
myomata  would  influence  the  physician  in  making  a  diagnosis  of  uterine  myomata 
instead  of  fil)roma  of  the  ovary.  A  suljperitoneal  myoma  may  be  just  as  freely 
movaljle  as  was  this  ovarian  tumor. 

Gyn.  No.  10491,     Path.  No.  6712. 

Fibroma  of    the   o  v  a  r  y  ;    m  u  1  t  i  j)  1  e    u  ferine    m  y  o  m  a  t  a  . 

R.  B.,  aged  twent3^-nine,  colored.  Admitted  May  14;  discharged  June  8, 
1903.  The  cervix  was  high  up,  soft,  and  normal  in  size.  Filling  Douglas' 
pouch  was  a  very  hartl  mass.  Occupying  the  lower  abdomen,  and  extending  as 
high  as  the  umbilicus,  was  what  appeared  to  be  a  myomatous  uterus.  "When 
the  abdomen  was  opened,  the  tumor  filling  the  cul-de-sac  proved  to  be  a  fibroma 
of  the  ovary.     The  myomatous  uterus  and  the  ovarian  tumor  were  removed. 

Path.  No.  6712.  The  uterus  contained  submucous,  interstitial,  and  subperi- 
toneal myomata.  It  measured  10  x  17  x  20  cm.,  and  was  free  from  atlhesions. 
The  fibroma  of  the  ovary  measurc^d  5  x  10  x  10  cm. 

Uterine  myomata  are  very  common.     Fibroma  of  the  ovary  is  relatively  rare. 

Ascitic  fluid  is  a  common  accompaniment  of  fibroma  of  the  ovary,  excep- 
tional with  myoma,  although  it  may  occur  as  noted  on  p.  30.  Accordingly,  if 
we  have  a  solid  pelvic  tumor  and  also  ascites,  w^e  may  strongly  susj^ect  a  fibroma 
of  the  ovary.  This  assumption  becomes  almost  a  certainty  if  the  uterus  is  normal 
in  size  and  free  from  myomata. 

^^^lat  has  been  said  concerning  ovarian  fil)romata  applies  equally  well  to  the 
slow-growing  sarcomata  of  the  ovary. 

Ovarian  Cysts. 

As  a  rule,  the  diagnosis  betwe(Mi  uterine  myomata  and  ovarian  cysts  is  easily 
established,  but  there  are  certain  cases  in  which  it  is  exceedingly  difficult  to  de- 
cide whethci-  the  gi'owth  springs  from  the  ox'ary  oi'  uterus.  The  following 
cases  illustrate  this  point  \-("ry  well. 

M  y  o  m  a  t  a  H  c  s  c  m  b  1  i  n  g  ( )  \-  a  r  i  a  11  Cyst  s  .  -In  (".-isc  lOo.").")  the 
abdominal  walls  were  xrvy  lax.  A  smoolli  i-ouiid('(l  mnss,  aboiii  10  cm.  in  dia- 
metei',  lay  in  the  pch'is.  It  could  be  displaced  lo  aii}'  part  of  the  abdomen. 
The  vaginal  outlet  was  markedly  relaxed;  the  fimdus  was  in  retroposition.  It 
was  impossible  to  detei'inine  whether  or  not  the  alxlominal  tumor  had  any  con- 
nection with  the  uterus.  ( )n  account  of  its  excessi\-e  mobility,  the  tunioi'  was 
thought  to  be  an  owiiian  cyst .  When  the  nb(lomeii  w;is  o|)eiied.  it  pro\'ed  to  be 
a  pedunculated  subperitoneal  myomn. 

In  Case  !()!)'.l  the  pelxis  was  lilled  with  a  i-ounded,  sliuhlly  m<i\able.  and  a])- 
parently  lluctUMUt  tumor.  .\t  o|ier;ition  the  eiil;ii-g("nient  was  found  to  be  due 
to  an  interstitial  m\'oma. 


496 


MVOMATA    OF    THK    ITKHUS. 


In  Case  10204.  in  whicli  llie  entire  abdomen  was  greatly  clisteniled,  the  clinical 
signs,  even  under  ether,  strongly  suggested  an  ovarian  cyst,  and  yet  the  tumor 
proved  to  be  a  niyointitoiis  uterus. 

In  Case  7'2iV-\  the  soft  and  irregular  boggy  feel  of  the  enlarged  uterus  strongly 
suggested  a  dermoid  cyst  glued  to  the  surface  of  the  uterus.  At  operation  an 
iiitei'stitial  m\'oina  was  found. 


Fk;.  Ij()7. — A  Myomatous  Utekus  Mistake.n  fok  an*  Ovakian  Cyst. 

Ciyii.  No.  97.36.  On  section  of  the  abdomen  the  tumor  was  found  to  have  a  double  set  of  blood-ve.ssel,s.  .\n 
attempt  was  made  to  puncture  it.  on  the  supposition  that  it  was  an  ovarian  cyst.  No  fluid  was  obtained,  and  on 
enlarginK  the  incision  it  was  found  tliat  the  tumor  was  a  .soft,  boggy,  myomatous  uterus,  with  tlie  ovaries  plastered 
on  its  posterior  surface. 

The  right  round  ligament  is  clearly  seen  in  the  drawing.  The  rectum  was  also  firmly  adherent  to  the  tumor. 
Removal  of  the  uterus  was  difficult  on  account  of  iiifl.ammatory  tissue. 


In  Case  9730  (i'ig.  -'A)!)  the  myomatous  uteinis  simulated  an  o\"arian 
cyst  so  closely  that  e\'en  after  the  abdomen  wasopem^d  an  attemi)t  was  made  to 
evacuate  it. 

A  cystic  myoma  may  .sometimes  be  felt  on  digital  examination  as  a  boggy 
mass.  This  was  noted  in  Case  9030.  Occasionally  on  abdominal  palpation  a 
doughy  sensation  was  noted,  as  in  Case  8251. 


DIFFER KXTIAL    DIACXOSIS. 


-19- 


A  Parasitic  .M  y  o  in  a  w  i  t  h  Ascites.*  — On  p.  35  Case  P.  is 
reported  in  full.  This  ])atient  had  a  tremendous  al)dominal  enlargement  and  a 
drawn  facial  expression.  Dulness  in  front,  tympany  in  the  flanks,  and  marked 
fluctuation  were  elicited.  From  the  physical  signs  we  were  sure  that  the  patient 
had  a  very  large  ovarian  cyst.  It  was  imi)ossil)le  to  get  the  previous  history  from 
the  patient,  as  she  was  weak  mentally.  CJuided  solely  by  our  findings,  we  made 
a  diagnosis  of  ovarian  cyst, 
but  in  this  the  famih'-  phy- 
sician, Dr.  I].  H.  Hoi)kins, 
did  not  concur.  He  in- 
sisted that  the  patient  had 
a  myoma  with  ascites,  be- 
cause he  was  sure  that  the 
patient  had  hatl  a  solid 
uterine  tumor  for  several 
years  before  the  appear- 
ance of  any  fluid.  On 
opening  the  abdomen  we 
found  a  pedunculated  my- 
oma which  received  nearly 
all  its  nourishment  from 
the  omentum  and  bladder 
(Fig.  25,  p.  36).  In  the 
abdomen  were  51,000  c.c. 
of  ascitic  fluid.  The  tym- 
pany in  the  flanks  was  due 
to  the  fact  that  the  intes- 
tines were  held  back  by  the 
tumor  and  the  omental  ^'^^-  sos. 
vessels,  and  even  if  they 
had  Ijeen  free,  the  abdom- 
inal distention  was  so  great 
that  the  mesentery  of  the 
small  bowel  would  not 
have  allowed  the  intestine 
been  present  over  the  anterior  abdoiniii;d  wall. 

S  i  m  pie  0  v  a  r  i  a  n  ('  y  s  t  s  P  e  s  e  in  b 
the  ovarian  cyst  is  irregulai'  in  shape,  fills  the  pehis,  and  spi-eads  out  into  the 
broad  ligament,  it  may  closely  resemble  a  cystic  myoma.  W'e  have  such  an 
example  in  I'^ig.  .'JOS.  The  jumoi-  is  vei-y  iiM'egulai'  in  shape  and  lobulated:  the 
uterus  rests  in  a  depi-ession  neai-  the  u])i)er  ami  anterioi-  surface  of  the  cyst.     It 

*  Thomas  S.   ('ullcii.  .\   Scries  of  .Mislaivcn   (iynccoloiiic   I  liaiitinscs.  .loiir.  .\.  .M.  .\..  .\()\rinljer 
19,  1901. 


A  Mi'LTii.ix  ri.Aii  0\AniA\  CvsT  in  Fokm  Kksk.muling  a 
Cystic  Myoma.  (J  nat.  size.) 
tiyii.  No.  11133.  Path.  No.  7364.  The  mult ilocular  ovarian  c.vst 
arising  from  the  right  ovary  is  markedly  lolnilateil  ami  irregular  in  form. 
It  has  evidently  filled  the  pelvis  completely,  and  been  held  firmly  in 
l)lace  by  the  uterine  attachments.  In  form  anii  in  its  relation  to  the 
uterus  it  bears  a  close  reseml)lance  to  the  cystic  myoma  seen  in  Fig. 
8S,  p.   111. 


lo  reach  the  surface,  and  dulness  would  still  ha\'e 
i  n  "■    .M  \"  o  in  a  t  a  .       \\  here 


498 


MYOMATA    OF   THK    UTERUS. 


i.s  clearly  evident  that  this  tumor  was  hnuly  wedged  in  the  })elvis.  (In  referring 
to  Fig.  SS  f  J).  Ill),  where  a  xrvy  large  eystie  inyonia  was  present,  it  will  be  seen 
that  both  tumors  l)ear  a  striking  resemblance  to  each  other  in  form  and  also  in 
the  relation  of  the  uterus  to  the  tumor,  lioth  of  them  naturally  yielded  a  cystic 
feel  on  bimanual  examination. 


Bilateral  Ovarian  Cysts  with  Papillary  Masses  on  Their  Surfaces  and  also  on 
THE  Peritoneum  of  the  Uterus. 

Occasionally  the  uterus  may  be  wedged  in  between  cystic  tumors  of  both 

ovaries.     If  these  are  \-ery  tense  and  covered  with  papillary  masses,  myoma  may 

be  strongly  suspected.     In  Fig.  309  we  have  an  example  of  such  a  condition. 

Both  ovaries  have  been  converted  into  multilocular  ovarian  cysts,  the  left  being 


Fig.  309. — Bilater.\l  Ovari.\.n  Cysts  with  P.\pillary  Masses  ox  Their  Surfaces.     (§  nat.  size.) 
Gyn.  No.  9608.     Path.  No.  5799.     Both  ovaries  have  been  converted  into  multilocular  cysts,  and  on  their 
outer  surfaces  are  papillary  mas.ses.     The  left  lay  deeper  in  the  pelvis.     .Vttaehed  to  the  surface  of  the  uterus  are 
several  small  papillary  masses,  indicated  by  a       From  the  general  contour  of  the  pelvic  mass  it  might  be  mistaken 
for  a  uterus  with  multiple  myomata. 

the  larger.  Hoth  are  covered  with  shaggy  papilloiiialous  growths.  The  cyst 
on  the  left  side  has  been  firmly  held  in  Douglas"  sac  by  the  uterus.  In  such  a  case 
the  growths  might  readily  be  mistaken  for  soft  myomata  with  secondary  nodules 
on  their  .surfaces.  Where  the  cysts  have  very  thin  walls,  however,  little  cUfficulty 
should  be  encountert-d. 


DIFFERENTIAL    DIAGNOSIS. 


499 


Omental  Metastases. 
Where  one  or  hotli  ovaries  arc  oairinoiiiatous  and  ])ortions  of  the  growth  are 
seen  on    the  surface   of    the    tumor,    it    is    not   unusual    to    find   a   secondary 


Carci  noma       / 
of    Ovar\ 


Fig.  310. — Small  Utekine  Mvomata;  Cahcinoma  ok  tmk  Ovahy  with  \'ery  Lau<!e  Omentai,  Metastase.s. 

Path.  No.  4878.  The  uterus  contains  two  small  interstitial  ami  one  subperitoneal  niyoinata.  The  left  ovary 
is  small,  but  carcinomatous  nodules  jirojcct  from  its  surface.  The  lower  part  of  the  omentum  contains  a  larpc 
metastatic  carcinomatous  growth.  This  is  lohiilatcd,  lias  a  definite  framework  of  connective  tissue,  and  the  inter- 
vening lobules  consist  of  carcinomatous  tissue  of  the  .same  type  as  that  of  the  primary  growth  in  the  ovary.  Bi- 
manual examination  in  such  a  case  reveals  a  small  myoma  on  the  surface  of  llie  uterus,  and  iho  natural  assumption 
would  be  that  the  omental  >;rowlh  was  merely  a  subperitoneal  nodule. 

carciiioiiiatous  iiniilical  ion  of  llie  onieiiluni.  Tiiis  may  he  limited  (o  llic 
h)\vcr  end  of  the  omenlum.  or  occur  as  mimerous  foci.  The  nodules  may  he 
small  or  reach    xcry  lai'ii'e   ])ro|»ort  i(dis.      W'iici-e,  on  himanual  examinalion.  the 


500  MYOMATA  OF  THK  ITERUS. 

Uterus  is  found  lo  Ix- soiiicwliat  cnlarpMl,  and  where  one  or  more  small  myomata 
are  detected  on  its  surface,  as  in  V\ii.  olO.  the  natural  infen^nee  is  that  the  abdomi- 
nal growth  is  also  myomatous.  Some  of  the  omental  metastases,  however,  are 
not  rounded,  hut  have  sharp,  clean-cut  edges,  reminding  one  of  the  lower 
margin  of  the  liver.     In  such  cases  no  confusion  should  exist. 

Ruptured  Rectal  Diverticula. 
Tile  following  ca.se  clearly  illustrates  the  great  difiieulty  sometimes  encount- 
ered in  making  a  positive  diagnosis  between  uterine  myomata  and  other  pelvic 
lesions.     Not  until  the  abdomen  was  opened  were  we  sure  that  the  enlargement 
was  not  uterine  in  origin. 

S.,  C.  H.  I.  (February,  1904),  Path.  No.  7276. 

Diagnosis:  P  e  1  \-  i  c  abscess  w  i  t  h  r  e  t  r  o  v  e  r  t  e  d  m  y  o  - 
m  a  t  o  u  s  uterus.  A  c  t  u  a  1  c  o  n  d  i  t  i  o  n  :  Rectal  diverti- 
cula with  r  u  p  t  u  1'  e  i  n  t  o  the  s  u  r  r  o  u  n  d  i  n  g  fat.  produc- 
ing a  d  e  f  i  n  i  t  e  t  u  m  o  r  :  s  m  all  abscess  b  e  t  w  e  e  n  the  t  u  m  or 
and   the   pelvic    floor   (Fig.  311). 

This  patient  was  sixty  years  of  age.  For  s(jme  time  she  had  experienced 
slight  difficulty  in  defecation.  The  stools,  however,  were  perfectly  normal  in 
caliber.     For  several  days  she  had  had  a  temperature  of  from  100°  to  103°  F. 

On  vaginal  examination  the  uterus  was  somewhat  enlarged.  Posterior  to  it, 
and  apparently  continuous  with  it,  was  a  glolmlar  mass.  This  was  very  hard, 
and  resemi)led  a  myoma  in  contoui'.  There  was,  howcN'er,  a  hard  ridge  ()\'er  its 
lower  portion,  as  is  so  often  noted  where  a  jx'lvic  abscess  exists. 

A  small  incision  was  made  in  the  vaginal  vault,  just  posterior  to  the  cervix. 
and  aftei-  the  mucosa  had  been  peeled  back,  Douglas'  pouch  was  entered  with  a 
pair  of  blunt  artery  forceps.  A  small  amount  of  pus  and  a  few  flakes  of  fibrin 
escajK'd,  but  th(>  mass  was  in  no  way  diminished  in  size.  Pvealizing  the  presence 
of  an  unusual  condition,  the  opening  in  the  vault  was  packed  and  the  abdomen 
immediately  entei'ed  fi-om  above.  Filling  Douglas'  sac  almost  completely  was  a 
tumor  mass,  evidently  sjwinging  from  the  sigmoid  flexure.  This  mass  had  rotated 
through  an  angle  of  90  degrees  and  had  become  firmly  embedded  in  the  ])elvis. 
It  closely  resembled  a  rectal  cancer.  It  w^as  carefully  brought  out,  and  an  end- 
to-end  anastomosis  done.  A  portion  of  the  descending  colon  was  brought  up  into 
a  small  incision  in  the  left  inguinal  region  and  made  fast.  It  was  necessary  to 
make  an  artificial  opening  at  this  point  on  the  fourth  day.  The  patient  made  a 
satisfactory  i-ecovery. 

Path.  No.  7276.  On  laying  the  tumor  open  we  found  two  rectal  diverticula 
passing  out  into  the  adipose  tissue  and  comnmnicating  with  the  lumen  of  the  gut 
by  openings  not  more  than  1  mm.  in  diameter  (Fig.  311).     The  larger  diverticu- 

*  Thomas  S.  Cullen,  A  Series  of  Mistaken  (Jynecologic  Diagnoses,  Jour.  A.  M.  A.,  November 
19,  1904. 


differp:xtial  diagnosis. 


50 1 


lum  was  1  cm.  in  clianiotcr  and  filled  with  a  fecal  mass.  Its  fioor  had  given  way, 
and  the  surroundin'i;  fat  was  everywhere  infiltrated  with  inflammatory  })r()ducts. 
The  excessive  hardness  of  the  tumor  was  due  to  rej)lacement  of  the  fat  in  many 
places  by  recent  connective  tissue.  The  small  abscess  between  the  tumor  and 
the  pelvic  floor  was  due  to  the  extension  of  the  inflammatory  process  to  the  peri- 
toneum of  Doufilas'  pouch.  The  diverticula  were  lined  with  atrophic  mucosa. 
A  rectal  cxainiiiation  in  this  case  would  have  yielded  little  beyond  some  narrow- 
ing of  the  lumen  of  the  bowel,  which  is  often  present  in  cases  of  jK'lvic  al)scess. 


Fig.  311. — Tumor  of  the  Sigmoid  Flexure  Due  to  Rupture  of  Rect,\l  Diverticui..\  into  the  SuRHOUxniNG 

Adipose  Ti.ssue;  Small  Pelvic  .\b.scess. 
Path.  No.  7276  Tlie  lumen  of  the  bowel  below  the  promontory  of  the  sacrum  i.s  con.-^iderably  nurnnveii.  At 
this  point  is  a  definite  tumor  made  up  of  adipose  tissue.  Projecting  into  it  are  two  diverticula,  one  seen  in  longi- 
tudinal, the  other  in  cross-section.  At  the  point  indicated  by  the  three  arrows  the  diverticulum  has  given  way.  and 
its  contents  have  percolated  through  the  fat.  This  fat  on  histologic  e.xamination  shows  evidence  of  acute  and 
chronic  inflammation,  which  acct)unts  for  the  denseness  of  the  tumor,  lietween  the  tumor  and  the  pelvic  floor  is 
a  small  abscess.     The  tumor  was  at  first  thought  to  be  a  myoma,     (.\fter  Thomas  S.  ("ulleii.") 


Retroperitoneal  Sarcoma. 

Het r(i))crit()iii';il  abdoiiiiiial  lumoi's  arc  not  comiiKni.  ImiI  dcc-isioiially  one 
is  encounl ci'cd  whicli,  in  situalioii  and  lonii,  siiiiulalcs  a  iiivoina.  In  Mg.  -WI 
is  represented  a  large,  lobulalctl  growili,  which  oc(ai|>ic(l  ilic  lowci'  abdomen, 
aiul  which  in  geiici'al  contour  bore  sonic  I'cscmbhiiicc  lo  a  niyoiiia.  The  growth, 
however,  was  cystic,  and  the  utci-us  was  not  ciihii'gcd.  Tlic  jtaticnt  uiidcislood 
English  poorly,  and  consc(|uciitly  could  not  gi\'c  a  clear  history  of  the  de\"elop- 
ment  of  the  tuiiiof. 


502 


.MVOMATA    OF    TIIK    ITKRI'S. 


Gyn.  No.  9107.  Path,  No.  5265. 
A.  K.,  white.  Admitted  October  7;  discharged  Xoveiiiher  *),  1901.  The 
patient  first  noticed  a  tumor  in  the  abdomen  a  few  months  afjo.  It  has  increased 
rapidly  in  size.  For  the  i)ast  five  weeks  she  has  had  severe  pain  in  the  left  side 
of  the  abilomen.  The  patient  is  rather  anemic  and  poorly  nourished.  The 
abdomen  is  f2;reatly  distended  by  a  tumor,  which  is  most  ])rominent  in  the  umbi- 
lical reijion  and  ap])ears  to  be  semicystic.     It  is  irreiiularly  nodular,  and  very 


Fig.  312. — Retroperitonkal  S.\Hfu.MA.     (»  nat.  size.) 
Gyn.  No.  !(107.     Path.  No.  526.T.     The  tumor  was  of  rapid  growth,  and  had  developed  l)ehiiid  the  transverse 
colon,  to  which  it  was  intimately  adherent.     U  measured  1.5  .\  23  x  2.5  cm.     .\bove  the  transverse  colon  were  large, 
sharply  outlined,  loljulated  portions  of  the  growth.     The  general  contour  of  the  tumor  strongly  suggested  myoma, 
but  its  position  and  consistency  excluded  the  possibility  of  a  uterine  origin. 

freely  movable.  On  vaginal  examinatioii  no  communication  between  the  tumor 
and  the  uterus  could  be  determined. 

Operation  (Dr.  Iluniicn:  The  tumor  proved  to  be  a  ret  roixi'ltoneal  sarcoma 
(Fig.  .312)  that  lay  beneath  the  transverse  colon.  It  was  neces.sary  to  resect 
a  large  portion  of  the  colon  with  the  tumor.  The  patient  made  a  satisfactory 
recovery. 

Path.  No.  5205.  The  specimen  consists  of  an  o\'al-shaped  tumor,  25  x  23 
X  25  cm.     To  the  hnver  bordei'  of  the  tumor  is  attached  the  omentum,  and 


DIFFERENTIAL    DIAGXOSIS.  503 

across  the  surface  of  the  tuiiior  are  '22  em.  of  the  transverse  colon.  On  clo.'^e 
inspection  the  tumor  is  .seen  to  he  between  two  hirers  of  the  omentum,  and  is 
covered  with  peritoneum,  except  along  the  upper  hfth,  where  it  has  been  attached 
to  the  stomach.  The  tumor  presents  a  dirty  yellowish  color,  somewhat  suggesting 
omental  fat.  Scattered  throughout  the  omentum  are  numerous  nodules.  Some 
of  these  near  the  lower  edge  of  the  omentum  are  1  cm.  or  more  in  diameter. 
On  palpation  the  tumor  is  semifluctuant  and  apjx'ars  partly  cystic,  but  when  cut 
into,  the  tissue  seems  for  the  most  part  to  be  homogeneous  and  resistant. 

Histologically,  the  tumor  consists  of  cells  crowded  together,  with  no  definite 
arrangement.  The  shape  and  size  of  the  nuclei  vary  considerably.  Many  giant - 
cells  are  present.  Numerous  thin-walled  blood-vessels  are  scattered  throughout 
the  tissue.     The  tumor  is  a  retroperitoneal  sarcoma  with  omental  metastases. 

In  the  foregoing  we  have  given  merely  a  few  examples  of  the  difficulties 
occasionally  encountered  in  making  an  accurate  diagnosis.  We  have  in  one  in- 
stance opened  the  abdomen  on  the  supposition  that  the  patient  had  a  small 
and  adherent  myomatous  uterus.  A  primary  carcinoma  of  the  right  tube  was 
found*  with  extension  to  contiguous  parts.  In  another  case  a  mass  to  the  right 
of  the  uterus,  and  apparently  continuous  with  it,  seemed  to  be  a  myoma.  At 
operationf  it  proved  to  be  an  inoperable  carcinoma  of  the  ovary  which  had  spread 
out  into  the  broad  ligament  and  had  apparently  implicated  the  small  bowel.  On 
the  other  hand,  we  have  on  several  occasions  opened  Douglas'  pouch  per  vagi- 
nam,  on  the  assumption  that  a  pelvic  abscess  existed,  only  to  find  no  abscess, 
but  an  adherent  retroverted  myomatous  uterus. 

The  diagnosis  of  uterine  myomata  is,  as  a  rule,  easy;  nevertheless,  in  a  certain 
number  of  cases  the  real  condition  cannot  be  definitely  established  until  the 
abdomen  is  opened. 

*  Thomas  S.  CuUen,  Primary  Carcinoma  of  the  Right  Fallopian  Tnhe,  Johns  Hopkins 
Hosp.  Bull.,  1905,  vol.  xvi,  p.  397. 

t  Thomas  S.  CuUen,  A  Series  of  Mistaken  Gynecologic  Diagnoses,  Jour.  A.  M.  A.,  November 
19.  1904. 


CHAPTEE  XXMIT. 
THE  EFFECT  OF  REMOVAL  OF  THE  OVARIES  ON  UTERINE  MYOMATA. 

In  the  early  clays  of  the  hospital  hysterectomy  wtis  a  more  formidaljle  oper- 
ation than  it  now  is.  and  when  removal  of  the  uterus  was  especially  difficult, 
the  ovaries  were  taken  away  in  the  hope  that  the  tumor  would  gradually  decrease 
in  size,  or  at  least  remain  dormant.  In  25  cases  only  the  tubes  and  ovaries  were 
removed,  and  in  12  of  these  we  have  been  successful  in  learning  the  subsequent 
history.  From  the  accompanying  table  of  the  cases  (page  505)  we  get  some  very 
interesting  data. 

In  4  of  the  cases  no  uterine  bleeding  was  noted  after  operation.  In  Cases 
1373  and  1405  it  appeared  once,  and  in  Cases  182  and  516  three  times.  In  Case 
143  it  was  regular  for  a  year,  and  in  Case  213  bleeding  occurred  at  irregular 
inter\-als  for  a  year.  In  Ca.se  1949  bleeding  persisted  at  irregular  intervals  until 
the  uterus  was  removed  four  }'eai's  later.  These  figures  tend  to  show  that 
removal  of  the  ovaries  caused  ces.sation  of  the  bleetiing,  either  at  once  or  in  the 
course  of  a  year.  It  will  be  noted  from  the  table,  however,  that  in  no  case  had 
the  myomatous  uterus  reached  large  proportions. 

In  10  of  the  cases  the  ])atients  were  completely  relieved  of  their  former  pelvic 
symj^toms.  In  Case  891  the  patient's  health  five  years  later  was  "very  bad." 
She  had  pain  on  defecation  and  micturition,  and  was  exceedingly  nervous.  One 
patient  (Case  1949)  was  reachnitted  to  the  hosjntal  four  years  later,  and  the 
densely  adherent   myomatous  uterus,  which   choked  the  pelvis,  was  removed. 

We  have  from  time  to  time  heard  of  uterine  myomata  spontaneously  dis- 
appearing or  \anishing  after  renio\-al  of  the  ovaries,  but  have  looked  uj)on  such 
rejjorts  with  considerable  incredulity.  We  have  one  case,  however,  where  such  a 
change  evidently  took  j)lace.  On  section  of  the  abdomen  in  Case  143  the  myoma- 
tous utei'us  completely  filled  the  ]»elvis;  both  tubes  and  ovaries  were  removed. 
Two  and  a  half  years  later  the  patient  was  examined.  She  had  gained  40  pounds. 
The  uterus  was  small,  antejjosed,  and  no  trace  of  the  myoma  remained. 

We  now  remove  the  myomatous  uterus,  wherever  necessary,  saving  the 
ovaries  if  normal.  The  knowledge  gained  from  the.se  cases,  however,  certainly 
suggests  the  adN'isability  of  removing  the  ovai'ies,  where  feasible,  in  those  cases 
in  which  hysterectomy  is  impos.^ible. 


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CIIAPTKIJ   XXIX. 
ABDOMINAL  MYOMECTOMY. 

Any  operation  that  has  for  its  aim  the  conservation  of  tho  uterus  instead  of  its 
removal  must  always  be  of  particular  interest  to  l)otli  suigeon  and  patient. 
We  have  carefully  examined  the  cases  admitted  to  the  Johns  Ho])kins  Hospital 
fi-oin  the  time  it  ojx'ncd,  in  ISSi),  until  July  1,  I'.KHi.  In  our  considei'ation  of 
the  suhjet-t  we  have  also  included  cases  of  i)atients  operated  u])on  at  the  Church 
Home  and  Infirmary,  the  Caml)ridu;e  (Md.)  Hosi)ital,  and  the  Frederick  Emer- 
gency Hospital.  In  that  period  we  have  had  296  cases  of  uterine  myomata 
in  which  the  conservative  method  was  adopted.  In  the  following  pages  we  shall 
give  Ijriclly  the  salient  features,  and  then  discuss  fnlly  the  various  complications 
accom))anying  or  following  inmiediately  after  operation.  Those  cases  in  which 
death  occurred  are  i-eported  in  detail. 

Letters  have  been  sent  to  nearly  all  the  patients,  and  it  is  interesting  to 
learn  the  condition  years  after  th(>  myomectomy. 

.M}'omectomy  naturall}-  falls  into  two  main  sul)(livisions: 
1.   Abdominal  myomectomy. 
-.   \'aginal  myomectomy. 

Before  j)roceeding  to  a  detailed  description  of  the  oj)ei'ation  and  its  various 
(■onij)licalions.  we  will  partially  outline  the  salient  clinical  features  in  cases  re- 
([uiring  abdominal  mycjuiectomy. 

Color. — Of  the  21)()  patients,  2.50  were  white  and  4(1  were  colored. 
Naturally,  the  whites  outnumber  the  blacks,  but  the  marked  i)reponderance  of 
white  patients  coming  to  abdominal  myomectomy  is  due,  in  part  at  least,  to  the 
fact  that  in  the  colored  the  tubes  are  more  fre([uently  the  seat  of  inflanunatory 
troul)l(\  wliich  usually  necessitates  a  hysterectomy  instead  of  a  myomectomy. 

Age.  In  all  but  1.")  cases  we  have  I'ecoi'ds  of  the  age  at  the  time  of 
operation. 

ABDOMINAL  MYOMECTOMIES. 

1 9  years  of  age 1   case 

Between  20  and  30  years  of  age 43  cases 

Between  30  and  40  years  of  age 137       " 

Between  40  and  4o  years  of  age 62       " 

Between  4.")  and  oO  years  of  age 19       " 

Between  ,50  and  60  years  of  age 17       " 

Between  60  and  70  years  of  age 2       " 

Ages  not  recorded 15       " 

Total 296       " 

506 


ABUU-MIXAL    MYO.MKCTU.MY.  5U7 

The  youngost  ])atioiit,  wlio  was  nineteen  jTars  of  age  (Case  9037).  had  a 
small  adenoniyonia.  2.')  <'iii.  in  diameter,  removed  from  the  right  uterine  horn. 

It  wall  further  be  noteil  that  at  least  38  out  of  a  total  of  296  patients  were  over 
forty-five  years  of  age,  the  oldest  being  sixty-six.  This  patient  (C'asc^  o279) 
had  an  intraligamentary  myoma,  6  x  8  x  10  cm. 

It  is  generally  conceded  that  myomectomy  is  more  dangerous  than  hyster- 
cctomv.  and  conse(|uently,  after  the  menopause,  it  is  usually  wiser  to  remove  the 
uterus  than  to  enucleate  the  myomata.  There  are,  however,  some  excejjtions. 
When  there  is  only  one  myoma  and  this  is  attached  to  the  uterus  by  a  narrow 
pedicle,  as  in  Case  9118,  myomectomy  is  naturally  the  easier  and  safer  operation. 
In  looking  back,  it  is  always  easy  to  see  where  one  might  have  shown  l)etter 
judgment  in  the  selection  of  the  safer  operation.  For  example,  in  Cases  1422. 
5279,  and  6047,  myomata  were  enucleated  from  the  broad  ligament.  In  such 
cases  we  now  know  that  it  is  very  difficult  to  obhterate  the  resultant  space,  and 
hysterectomy  is  much  safer.  Again,  in  patients  who  have  passed  the  climac- 
teric no  possiljility  of  pregnancy  or  the  preservation  of  the  menstrual  fvuiction 
exists  to  compensate  for  the  increased  risk. 

Furthermore,  we  know  that  when  many  incisions  are  made  into  the  uterus, 
the  risk  is  materially  increased,  and  yet  in  Case  5153  we  removed  11  myomata 
through  7  incisions,  and  in  Case  6395,  15  myomata  were  enucleated.  Little  is  to 
be  gained  in  saving  such  organs  after  the  menopause. 

In  Case  5493  the  nodule  was  a  submucous  myoma,  and  during  its  removal 
the  uterine  cavity  was  opened  throughout  its  entire  length.  Here,  hkewise, 
the  increased  risk  was  in  no  way  compensated  for  by  the  ultimate  results. 

Although  myomectomy  is  always  attended  with  an  increased  risk  over 
hysterectomy,  after  the  menopause  the  l)lood-supply  of  the  uterus  is  nuich 
diminished,  and  the  i)ower  of  absorption  from  this  organ  lessened.  This  is 
shown  ])y  our  results:  every  one  of  the  38  patients  oj)erated  upon  after  the 
menopause  recovered  from  the  operation,  and  the  greater  number  wci'e  pci'fectly 
well  years  aftei'. 

Single  or  Married.— Of  the  29()  patients  that  underwent  alMlomiiial  iiiyoiiiec- 
tom\',  101  were  single;    ISO  were  niai-ried;   in  6,  data  were  lacking. 

These  figures  are  of  only  I'elative  value,  as  the  morals  of  some  of  the  white 
as  well  as  the  colored  patients  were  not  above  (piestion. 

The  Relation  of  Uterine  Myomata  to  Pregnancy.  In  00  of  the  myomectomy 
cases  in  married  women  during  the  child-bearing  ju'i'iod  we  have  dehnite  data  as 
to  pregnancy.  Of  this  number,  59  have  had  children.  A  few  have  been  the 
mothers  of  large  families,  but  in  a  large  projiortion  onl\-  one  oi-  two  chilihcn  have 
been  boi'n.  In  .■■)2  (35.1  pel'  cent . )  the  ])al  ient  had  ne\'ei-  been  pi'egnant  up  to  t  he 
time  of  entering  the  hos))itah  Our  figures,  thercfoi-e,  faxdi'  the  \-iew  tliat  myo- 
mata ma}'  possibly  cause  stei'ihty. 

The  Location  of  Myomata  Removed  by  the  Abdominal  Route.  IVom  a  surgi- 
cal standpoint,  it  seems  advisal)le  to  divide  the  myoinat.a  into  the  following  geo- 
gra])hic  groups: 


oOS 


MYOMATA    OF    THK    UTP:RUS. 


Fig.  313. — .\  Peduncul-'^ted  Subperitoneal 
Myom.^. 
Gyn.  No.  19.50.  The  patient  was  forty 
years  old.  The  uterus  had  been  rotated  to  the 
left  to  accommodate  the  myoma,  which  was  at- 
tached to  the  posterior  surface  of  the  uterus  by 


1.  Subperitoneal  i)e(liiiR'ulatetl  inyoniata. 

2.  Interstitial  (ineliuling  those  that  are  partly  sul)peritoneal). 

3.  Submucous  (inehuling  those    partly 
interstitial. 

4.  Myoniata  of  the  broad  ligament  or 
int raligamentary  mj'omata. 

5.  Subvesical  m3'omata. 
(i.  Cervical  myomata. 
7.  Adenomyomata. 
In  all  but  25  of  the  296  cases  we  have 

definite  data  as  to  the  location  of  the  my- 
omata. In  some  instances  subperitoneal 
pedunculated  nodules,  interstitial  tumors, 
and  submucous  myomata  were  removed 
from  the  same  organ. 

Subperitoneal        Fed  u  n  c  u  - 
1  a  t  e  d       M  y  o  m  a  t  a  .  — In     49     cases 

a  narrow  pedicle.     Abdominal  myomectomy  was  peduUCUlated  UlVOUiata  WCrC  rcmOVCd,  and 

performed.     The  patient  made  a  good  recovery.  '  -  .  .    .    , 

Fourteen    years    later    she  writes,    "Health    not  in  at  Icast  8  of  thcSO  CaSCS  mtcrstltUll  myO- 

cood.     Trouble  not    connected  with  operation,"  ,         PnUclpatcd 

showing  that   no  new  myomata  have  developed.  Ul'ita  ^^C1C  aibO  enUCiedlLU. 

This   is   a    case   in   which   myomectomy   is    less  J^l  CaSC  7220  the    UiyOUia    meaSUrod    14 

dangerous  than  hysterectomy.  -r       i        i  '       i  •  i-    i 

X  19  cm.  It  had  rotated  on  its  pedicle 
from  right  to  left  through  an  angle  of  180  degrees,  and  was  covered  with 
dense  vascular  omental  adhesions.     (See  Fig.  18,  p.  22.) 

The  myoma  in  Case  8310  was  nearly  as 
large  as  a  uterus  at  full  term.  Its  pedicle 
consisted  of  the  fundus  and  cenax,  and  was 
2  cm.  in  length.  The  cervix  itself  had  been 
))ulled  high  u]j  toward  the  jx'lvic  brim. 

The  myoma  in  Case  67S1  was  approxi- 
mately 9  cm.  in  diameter,  and  almost 
completely  enveloped  in  very  vascular 
omental  adhesions.  The  greater  number 
of  ju'dunculated  myomata  were  fi'eely 
movable. 

In  Fig.  313  we  have  an  example  of  a 
large  subperitoneal  myoma  that  was  easy 
of  removal.     The  myoma   represented   in 

Fig.    314,    on   the   other  hand,   was  attached        Abdominal  myomectomy  was  performed,  and  the 

'  patient  reported  that  she  was  in  very  good  health 

to  the  uterus  over  a  broad  area.     It  was     .sixteen  years  later, 
difficult  to  decide  whether  the  myoma  alone 

should  be  removed,  or  whether  a  hy.sterectomy  would  be  the  .'^afer  procedure. 

Myomectomy  was  done,  and  the  patient  was  in  good  condition  sixteen  years  later. 

Interstitial    Myomata.  — The  majority  of  myomata  are  intersti- 


FlG.  314. A    L.\RGE  SuBPERITOXE.\L  MyOM.\. 

Gyn.  No.  1112.  The  myoma  rises  high 
out  of  the  pelvis  and  is  attached  to  the  posterior 
surface  of  the  uterus  by  a  rather  broad  pedicle. 


ABDOMINAL    .M  V(  )MK('T()M  V 


509 


tial  ill  their  iiicipiciic}'  and  linulually  ht'coiiie  subperitoneal  or  suhinufous. 
Consequently,  we  should  expect  the  greater  nuniher  operated  u]jon  to  he  of  the 
interstitial  variety,  and  such  proved  to  be  the  case.  All  partially  subperitoneal 
niyomata  are,  to  a  great  extent,  interstitial,  and  as  the  operative  procedure  in 
both  instances  is  the  same,  Ave  find  it  wiser  to  include  them  in  the  same  group. 
In  202  of  the  296  cases,  that  is,  in  about  70  ])er  cent.,  interstitial  niyomata  were 
removed. 

Sub  m  u  c  o  u  s  M  y  o  m  a  t  a  .  — In  20  cases  submucous  niyomata  were 
removed.  Sometimes  it  is  possiljle  to  remove  the  myoma  without  opening  the 
uterine  cavity,  but  in  others  the  myoma  encroaches  so  upon  the  cavity  that  its 
removal  is  impossible  without  entering  the  cavity  to  some  extent.  The  accom- 
panying table  gives  the  essential  features  in  all  the  cases  in  which  submucous 
myoma t a  were  found. 

SUBMUCOUS  MYOMATA  REMOVED  PER  ABDOMEN. 
T.^.BLE    Showing    Whether    Uterine    Cavity    was    Opened    or    not    During    Oper.^tion. 


510  MYo.MATA    OF    THH    UTKRUS. 

Ill  'A  casrs  it  was  possible  to  cmiclcatc  the  j)artly  subiiiucoiis  myoiiiata  with- 
out o])('iiiiii:  the  uterine  (•a^■ity.  In  4  cases  the  uterine  ea\'ity  was  only  slightly 
or  moderately  oi)ene(l,  and  in  7  cases  the  cavity  was  explored  for  nearly  its  entire 
length.  Tn  'A  cases  the  utei-us  was  deliberately  split  open  to  see  if  myomata  were 
present,  ami  in  2  out  of  the  M  myomata  were  detected. 

Hysterotomy,  or  sj^litting  of  the  uterus,  has  been  frequently  employed  by  our 
colleague.  Dr.  W.  W.  Kus.sell,  with  excellent  results.  In  Case  10351,  however,  a 
very  large  uterus  was  bisected,  and  28  nn'omata  were  removed  from  various  parts 
of  the  wall.  The  utei'us  was  then  sewn  together  again.  The  patient  died. 
Complete  tletails  of  her  case  are  foimd  in  on  page  537. 

In  C.  H.  I.,  B.,  one-third  of  the  uterine  cavity  was  saved,  and  the  i)atient 
menstruates  regularly.  In  C.  H.  I.,  1019,  in  which  a  partially  submucous  myo- 
ma, 10  X  10  X  12  cm.,  was  ])resent,  half  of  the  uterine  cavity  was  saved.  The 
menses  ceased  about  six  months  later,  jiossibly  partly  as  the  result  of  a  marked 
cardiac  lesion. 

-M  y  o  m  a  t  a  o  f  t  h  e  B  r  o  a  d  L  i  g  a  m  e  n  t  .  — Seven  out  of  296  ab- 
dominal myomectomies  wei'e  for  myomata  of  the  broad  ligament,  which  some- 
times occurred  alone,  and  in  other  cases  associated  with  interstitial  or  peduncu- 
lated nodules.  The  intraligamentary  myoma  is  usually  easily  removed,  but  if 
there  is  much  oozing,  there  is  great  danger  of  an  accunmlation  of  l)lood  between 
the  peritoneal  folds,  and  this  later  may  become  infected,  giving  rise  to  a  l)road- 
ligament  abscess,  as  ha))])ene(l  in  Case  5359  (p.  553). 

S  u  b  V  e  s  i  c  a  1  .M  y  o  m  a  t  a  .  -  Subvesical  myomata  are  not  uncommon, 
but  are  usually  associated  with  other  myomata,  and  in  such  cases  hysterectomy 
is  the  safer  operation.  Two  of  our  abdominal  myomectomies  were  done  for  the 
removal  of  subvesical  nodules. 

In  Case  5332  a  subx-esical  myoma,  S  cm.  in  diametei',  was  removed,  and  the 
l^atient  was  perfectly  well  ten  years  later. 

In  Case  6762  a  subvesical  nodule,  6x6x7.5  cm.,  was  removed.  Iletention  of 
tu-ine  i-e(|uire(l  catheterization  up  to  the  twenty-third  day.  An  annoying  cystitis 
ju'i'sisted  for  ovei-  two  years,  and  now,  eight  years  after  operation,  is  much  better, 
but  apparently  the  patient  has  tabes  dorsalis. 

Cervical  M  y  o  m  a  t  a  .  — Cervical  myomata  that  caimot  b(>  enucleated 
per  vaginam  are  usually  so  hard  to  get  at  from  above  on  account  of  their  proxi- 
mity to  the  uterine  artery  and  ureter,  and  from  the  difficulty  of  obliterating  the 
resultant  space,  that  hysterectomy  is  generally  (he  (>asier  procedure.  In  two 
of  our  cases  single  cervical  myomata  have  been  removed  per  abdomen. 

In  Fig.  315  we  have  an  exam])le  of  a  myoma  that  was  attached  to  the  uterus 
so  low  down  in  the  cervical  region  that  its  removal  occasioned  much  difficult}-. 

In  Case  1033  a  small  cervical  myoma,  1.5x2  cm.,  was  icmoved  from  (he 
posterior  surface  of  the  cervix.  Nine  years  later  (No.  S415)  the  uterus  was 
removed  on  account  of  multiple  myomata. 

Case  G.,  in  which  a  large  cervical  myoma  with  part  of  the  vaginal  mucosa 


ABDOMINAL   MYOMECTOMY. 


511 


Tubf 


T'^a. 


was  reniovccl  per  ahdoincii  without  iiitcrniptin^  the  four  months'  pregnancy,  is 
reported  in  detail  on  p.  531. 

In  one  of  our  early  cases  (No.  1329)  a  myoma,  5  cm.  in  diameter,  was  re- 
moved from  the  fundus,  but  instead  of  attempting  to  enucleate  a  cervical  myoma, 
8  cm.  in  diameter,  we  removed  the  ovaries.  Of  course,  with  our  present  knowl- 
edge we  would  do  a  hysterectomy  and  save  the  ovaries. 

A  d  e  n  o  m  y  o  m  a  t  a  .  — In  five  cases  diffuse  or  discrete  adenomyomata 
were  removed  from  the  uterine  wall.  We  have  made  a  separate  division  of  this 
variety,  because  in  the  majority  of  these  cases  the  myoma  is  so  intimately  con- 
nected with  the  uterine  wall  that  it  cannot  be  peeled  out  and  must  be  cut  away. 
In  Cases  3600,  4415,  and  12036,  it 
was  necessary  to  cut  out  a  wedge  of  ^^-'--  ~~~-,^ 

the  uterine    wall    to    remove    the  ^^"^  '"^  -- 

growth.  In  cases  9024  and  12585 
the  myomata  were  more  circum- 
scribed and  could  be  dissected  out. 
All  these  cases  are  dealt  with  in 
detail  in  "Adenomyoma  of  the 
Uterus." 

Size  of  the  Myomata  Removed. 
— In  the  296  cases  we  have  in- 
cluded practically  every  case  in 
which  myomata  were  removed,  no 
matter  how  small  or  how  large. 
As  seen  from  the  records  of  the 
deaths,  the  removal  of  even  small 
nodules  may  prove  fatal. 

P  e  d  u  n  (•  u  1  a  t  e  d  Myo- 
mata.— 111  the  following  cases 
large  pedunculated  myomata  were 
removed:  in  Case  911S  a  subperi- 
toneal nodule.  16  x  Ki  \  22  ciii. ; 
in  Case  5826,  a  myoma  15  x  IS  x  20 
cm.;  ill  Case  5086,  a  myoma  17x2*)x29  ciii.,  and  in  Case  1(172  a  sub|tciit(»iieal 
nodule,  30x34  cm.  In  all  probability  the  largest  subix-iitoiieal  nodule  ever  re- 
moved was  from  Case  McA.  (see  Fig.  317,  p. 514).  Th(>  t  umor  weighed  89  j)ounds. 
and  was  attached  to  the  uterus  by  a  pedicle  only  a  few  centimeters  in  diameter. 

Interstitial  .M  y  o  in  a  t  a  .  — The  iiiterstitiat  t  uiiiors.  of  course,  do  not 
reach  such  large  projKJilions.  In  Case  lo.").")  an  interstitial  iiiyoiiia,  10  \  10x21 
cm.,  was  removed;  in  Case  1  JL'.")!')  one  15  cm.  in  diameter,  hi  (".  11.  1..  \\  .,  the 
tumor  measured  K)  cm.,  and  in  Cas(>  4!)25,  12x21  x  27  cm.  hi  tiie  last  case 
hysterectomy  followed  a  few  years  latei-  on  account  of  the  ap|)earance  of  other 
myomata.     (See  Fig.  331,  p.  562.) 


\ 


Fig.  315. — A  Difkicult  .Myo.mecio.my. 
Oyn.  No.  S389.  Path.  No.  4576.  At  the  junction  of 
the  cervix  and  fundus  was  a  myoma  about  7.5  cm.  long, 
n  was  exposed  with  tlifliculty  ami  removed,  .\fter  opera- 
tion the  patient  developeil  a  severe  cystitis.  Six  years 
later  she  was  perfectly  well. 


512  MYOMATA    OF    THE    UTERUS. 

S  u  I)  111  u  c-  o  II  s    M  y  ()  111  a  t  a  .  — Myoniata  of  this  variety  are  relatively 
small.     In  our  tirouj)  they  varied  from  1   to  10  cm.  in  diameter,  the  average 
])eing  about  o  cm.     In  ('a.-;e  5447  the  myoma  reached  about  9  cm.  in  diameter 
and  in  C.  H.  I..  S..  10  cm. 
Successful  Removal  of  a  Pedunculated  Eighty-nine  Pound  Cystic  Myoma  Intact.* 

As  will  be  noted  from  the  following  history,  this  j)atient  was  cognizant  of  the 
fact  that  the  tumor  had  existed  for  over  twenty  years.  At  that  time  she  was 
under  the  care  of  Dr.  James  Bosley.  Further,  it  will  l)e  seen  that  this  large 
growth  did  not  prevent  her  from  looking  after  her  household  duties  until  a  short 
while  before  admission,  and  less  than  three  months  before  the  operation  she 
had  taken  a  ISO-mile  trip  with  no  ill  effects.  This,  so  far  as  we  can  learn,  is  the 
largest  myoma  of  the  uterus  that  has  been  successfully  removed.  The  patient 
is  now,  two  and  one-half  years  after  the  operation,  in  perfect  health. 

McA.     Path.  No.  10382. 

Mrs.  McA..  aged  fifty-eight,  was  seen  by  one  of  us  (CuUen)  in  consultation 
with  Dr.  Marshall  Smith,  June  25,  1906. 

History. — Twenty  years  ago  she  noticed  a  tumor  in  the  lower  abdomen,  and 
later  was  seen  in  consultation  with  Dr.  W.  T.  Howard,  who  at  that  time  advised 
an  operation.  Some  time  after  this  she  was  delivered  of  a  healthy  child,  now 
eighteen  years  of  age.  Tliis  patient,  although  suffering  from  a  large  alxlominal 
tumor,  was  able  to  go  around  and  to  do  her  work  until  three  weeks  before  T  saw 
her.  Her  chief  inconvenience  had  been  her  inability  to  lie  on  her  Imck  in  Ijed. 
And  sometimes  when  she  would  get  ''stalled,"  it  was  necessary  for  her  husband 
to  turn  her  over  quickly,  otherwise  she  would  have  suffocated.  For  two  weeks 
before  admis.sion  she  had  a  temperature  sometimes  reaching  as  high  as  103°. 
She  was  admitted  to  the  Church  Home  and  Infirmary  July  27,  1906.  There  was 
consid(>rable  edema  of  the  lower  part  of  the  abdomen  and  some  edema  of  the  legs. 
On  admission  to  the  hospital  her  temperature  was  100°  F. ;  pulse,  105.  On  the 
morning  of  operation  the  temperature  was  100°  F. ;  pulse,  100;  respiration,  normal. 

Operation,  July  'AO.  1906:  Prior  to  receiving  the  anesthetic  the  patient  was 
thoroughly  washed  and  all  preparations  for  operation  were  made,  so  that  she 
might  remain  as  .short  a  time  as  i)ossible  under  ether.  It  was  impossible  for  her 
to  lie  down,  conse<iueiitly  she  was  o|)erated  on  in  the  sitting  posture.  An  incision 
was  made  over  the  most  prominent  part  of  the  tumor,  and  I  attempted  to  punc- 
ture it;  the  growth,  however,  started  to  bleed,  and  no  cyst  fluid  escaped.  I 
continued  the  inci.sion  upward,  for  the  reason  that  many  large  veins  projected 
into  the  tumor  from  .some  structure  above.  The  incision  was  gradually  con- 
tinued ui)ward  until  the  xii)hoid  process  was  reached  (Fig.  316).  We  found 
that  the  large  vessels  going  to  the  tumor  were  omental  in  origin,  and  were  si)rea(l 
out  over  the  entire  upper  surface.     Some  of  them  were  fully  7  or  S  mm.  in  diam- 

*  Thomas  S.  Cullen,  A  Series  of  Interesting  Gynecologic  and  Obst  etric  Cases.  Jour.  A.  M. 
A.,  vol.  xlviii,  May  4,  1907. 


ABDOMINAL    M YOM KCTO.M Y 


513 


eter.  The  tumor  was  densely  adherent  to  the  anterior  and  to  the  lateral  ab- 
dominal walls.  These  adhesions  were  gradually  shelled  off  with  the  hand,  but  I 
had  to  use  the  utmost  care  and  do  all  liberating  under  sight,  as  the  rupture  of 
one  large  vein  might  have  caused  death  before  the  hemorrhage  could  have  been 
checked.  Accessory  vessels  also  passed  from  the  stomach  and  the  liver  to  the 
tumor.  The  pedicle  of  the  tumor  was  not  more  than  1.5  cm.  in  diameter,  and 
was  situated  directly  beneath  the  ribs.  On  removal  of  the  tumor  I  found  that 
I  had  brought  away  a  piece  of  liver  tissue  3  cm.  in  diameter.  We  had  no  liver 
needles  handy,  so  I  used  sharp  Hagedorn  needles,  running  the  eye  through  instead 
of  the  sharp  end.     This  device  answered  admirably,  and  the  liver  bleeding  was 


Fig.  316. — Abdominal  Enlargement  Due  to  a  Cystic  Myoma. 
The  abdomen  is  markedly  and  uniformly  distended,  and  the  growth  extends  down  almost  to  the  knees. 
It  will  be  noted  that  there  is  no  saKging  in  the  flanks.  Coursing  over  the  surface  were  very  large  vessels.  When 
it  is  realized  that  the  abdominal  incision  extended  fom  the  xiphoid  cartilage  down  over  the  entire  length  of  the 
tumor,  and  then  back  to  the  symphysis,  it  is  readily  seen  that  the  wound  was  nearly  4  feet  in  length,  (.\fter 
Thomas  S.  Cullen.) 

easily  checked  with  four  catgut  sutures,  llie  uterus  and  the  right  tube  and 
ovary  lay  under  the  surface  of  the  liver.  Anticipating  the  possibility  of  great 
difficulty  in  controlliiig  the  tumor,  wo  had.  jjrior  to  operation,  sterilized  a  large 
foot-bath  and  covered  it  over  with  a  sterile  sheet.  The  foot-bath  held  about 
one-third  of  the  tumor,  and  the  p(>rson  who  took  charge  of  it  was  able  to  guide 
the  tumor  in  the  desired  direction  without  allowing  it  to  slip  from  his  grasp. 
The  tumor  was  drawn  downward  and  outward,  and  finally  dcliNcrcil  from  the 
abdomen.  In  the  lower  part  it  was  extraperitoneal.  I  closed  the  abdo- 
men, but  left  a  small  cigarette  drain  in  the  extraperitoneal  pouch  just  over  the 
symphysis. 

Postoperative  history:    The  patient  stood  the  ojK'ration  wt^U.  but  was  com- 

33 


514  MYOMATA   OF  THE    UTERUS. 

nioncing  to  collapse  by  the  time  we  finished.     She  was  under  ether  for  one  hour 
and  twenty  minutes;  200  gi'anis  were  used.     The  operation,  from  the  incision  to 
complete  closure,  took  fifty-five  minutes;  a  much  longer  time  would  have  been 
consumed  had  it  not  been  for  the  combined  assistance  of  both  the  Johns  Hopkins 
and  Church  Home  staffs.     The  patient's  temperature  rose  to  102.2°  F.,  within 
eight  hours  after  operation,  but  had  dropped  to  100°  F.  by  evening.     The  highest 
pulse-rate  was  130.     There  was    no  postoperative  vomiting.     The   legs  were 
bandaged  on  account  of  the  edema.     The  patient  voided  urine  on  the  evening 
of  the  day  of  operation.     She  was  catheterized  only  once.     The  usual  after-treat- 
ment was  employed.     On  the  fourteenth  day  she  had  considerable  discomfort 
from  frequent  stools.     The  diarrhea  persisted  off  and  on  for  a  couple  of  weeks. 
At  this  time,  however,  tlie  weather  was  excessively  hot,  and  diarrhea  was  general 
throughout  the  hosjjital.     It  affected  chiefly  those  patients  who  were  somewhat 
weak.     The  patient,   on    admission    to    the    hospital,    weighed    174    pounds. 
Twenty-three  days  after  operation  she  weighed  80^  pounds.     The  condition  of 
the  abdomen  in  this  case  was  particularly  interesting.     I  did  not  even  resect  a 
portion  of  the  abdominal  wall,  because  we  had  to  save  as  much  time  as  possible 
during  operation.     At  the  first  dressing  it  was  noted  that  the  ribs  extended  out 
fully  6  inches  from  the  abdomen,  and  that  the  recti  muscles  lay  on  the  bed  on 
either  side,  while  there  was  a  good  deal  of  loose  and  wrinkled  skin  covering  the 
abdomen.     Another  interesting  point  was  that  the  gauze,  which  drained  the  ex- 
traperitoneal pocket  just  at  the  symphysis,  now  lay  in  the  middle  of  the  abdomen, 
as  the  tissues  were  gradually  contracting.     After  the  lapse  of  two  weeks  the  recti 
muscles  could  be  felt  gradually  contracting  and  coming  in,  and  the  costal  arch 
was  flattened  down  to  some  extent.     When  I  examined  her  six  weeks  after  opera- 
tion the  recti  muscles  were  well  up  in  the  abdomen,  being  not  over  10  cm.  apart. 
The  skin  had  contracted  down  wonderfully.     The  pendulous  skin  over  the  sym- 
physis had  retracted  to  a  marked  extent,  and  the  ribs  were  almost  in  their  normal 
position.     At  the  time  of  operation  there  was  a  good  deal  of  edema  of  the  ab- 
dominal walls.     There  was  also  edema  of  the  legs  and  of  the  buttocks.     Although 
the  utmost  care  was  used,  a  bedsore  developed  several  days  after  the  operation, 
there  being  a  black  slough  6  cm.  in  diameter  over  the  sacrum,  and  surrounded 
by  a  faint  red  halo.     It  had  resulted  from  pressure  on  the  table.     The  patient 
had  had  marked  edema  of  the  Ijack,  but  was  forced  to  sit  u\)  during  almost  the 
entire  operation.     After  she  went  home  she  ra[)idly  regained  her  strength.     The 
bedsore  gradually  diminished,  and   in  time  entirely  healed.     It  is  astonishing 
that  she  had  so  little  inconvenience  after  the  operation. 

Fio.  317. — Cross-section  op  a  Cystic  Myoma  Weighing  89  Poonds.  (1%  nat.  size.) 
The  pedicle  is  clearly  seen,  and  in  the  fresh  specimen  was  not  over  1.5  cm.  in  diameter.  Attached  to  the  top 
over  the  pedicle  are  the  tube  and  ovary,  and  near  the  tube  is  a  piece  of  liver  substance.  The  tumor  has  been 
converted  into  one  large  cavity,  the  walls  of  which  consist  of  muscle.  In  the  walls  are  numerous  cystic  spaces, 
particularly  well  shown  at  the  points  indicated  by  a.  There  are  several  large  cystic  dilatations  in  the  wall.  The 
largest  is  indicated  by  b.  The  myomatous  walls  vary  from  5  cm.  to  1  or  2  mm.  in  thickness.  At  the  point  c. 
■where  the  tumor  lay  over  the  vertebral  column,  the  wall  is  exceedingly  thin.  The  entire  inner  surface  is  lined 
with  partly  organized  blood-clots,  which  give  the  growth  a  very  shaggy  appearance.  The  entire  tumor  was  filled 
with  blood.     The  outer  surface  is  in  many  places  covered  with  adhesions  containing  large  vessels. 


li(..  .il7. 


515 


516 


.MVOMATA    OF    THI-:    UTERUS. 


Description  of  Tumor. — Path.  No.  103S2.  Miss  X.  Ellicott,  sii|H'rint('ii(leiit 
of  imrst's,  weighed  the  tumor  iiuniediately  after  its  removal;  the  net  weight, 
after  deducting  that  of  the  vessel  in  which  it  lay,  was  exactly  89  pounds.  The 
thin  part  lay  posteriorly,  otherwise  we  might  have  evacuated  the  tumor.  Had 
we  done  so,  however,  it  would  have  been  much  more  difficult  to  have  gotten  at 
the  large  vessels,  which  we  cncouutci'ed  at  almost  every  point.  Had  this  condi- 
tion jK'rsisted  much  loiiuci-.  the  jjosterioi"  wall  of  the  tumor  would  certainly  have 

gi^en  way,  and  then 
operation  would  have  been 
almost  out  of  the  question. 
As  it  was,  the  hardened 
specimen  collapsed  of  itself 
wh(^n  placed  on  the  table. 
Macroscopic  Examina- 
tion.— The  hardened  speci- 
men is  about  50  cm.  in 
length,  45  cm.  in  breadth, 
and  approximately  25  cm. 
in  thickness.  Over  the 
entire  anterior  surface  and 
laterally  are  numerous  ad- 
hesions. Attached  to  the 
upper  border  is  an  area  of 
omentum  20  cm.  in 
breadth,  and  the  hardened 
vessels  range  from  5  to  6 
nun.  in  diameter.  The 
pedicle  of  the  tumor  is  1.5 
cm.  in  breadth,  1  cm.  in 
thickness,  and  the  portion 
removed  is  1.5  cm.  in 
length.     Situated  just  be- 


FiG-  318. — Multiple  Myomectomy. 

Gyn.  No.   S462.     From  this  uterus  13  myomata  were  enucleated. 

The   large  kidney-shaped   tumor  on   the  rijiht   measured   7x7x14  cm. 

Practically  all  the  myomata  seen  were  removed,  with   little  injury  to 

the  uterus.     Six  years  later  the  patient  reported  that  her  general  health 

could  not  have  been  better.  Prior  to  the  operation  she  had  frequent  UCatll  the  ])edicle,  and  at- 
tached to  the  surface  of 
th( 


micturition  and  a  troublesome  pruritus  ani,   which  had  persisted  over 
two  years,  but  was  completely  relieved  by  operation. 

ovary,  is  a  piece  of 
liver  substance  3  by  2  cm.  (Fig.  317).  On  pressure  the  tumor  in  part  seems 
to  be  solid,  in  part  cystic.  At  operation,  when  I  attempted  to  puncture 
the  tumor,  nothing  but  blood  was  encountered.  Th(>  growth  is,  however,  evi- 
dently made  up  of  one  large  cystic  space  and  numerous  smaller  ones,  together 
with  the  semisolid  area.  Over  the  part  that  is  cystic  the  muscle-fib(>rs  have  been 
greatly  stretched  and  thinned  out,  and  there  are  little  hernial  })r()jections,  the 
picture  being  analogous  to  that  foimd  in  a  slightly  sacculated  urinary  bladder. 
On  section  the  greater  part  of  the  tumor  is  found  to  con.sist  of  one  cavity,  which 


ABDOMINAL  MYOMECTOMY.  517 

is  approximately  42  by  35  cm.  The  walls  vary  from  2  mm.  to  5  cm.  in  thickness. 
Only  at  one  point  is  the  wall  very  thin,  namely,  on  the  under  surface,  where  it 
lay  over  the  vertebral  column.  The  greater  part  of  the  wall  consists  of  simple 
myomatous  tissue,  but  at  numerous  points  small  cystic  areas  are  visible,  and  the 
tissue  has  undergone  the  characteristic  hyaline  tra,nsformation.  One  of  the  cysts 
measures  2  by  3  cm.  The  inner  surface  is  covered  with  blood,  and  the  greater 
part  of  the  tumor  is  filled  with  Ijlood  which  has  undergone  coagulation  during 
the  hardening. 

Microscopic  Examination. — On  histologic  examination  the  growth  is  seen  to 
be  made  up  of  typical  myomatous  tissue.  In  many  areas  hyaline  transforma- 
tion has  taken  place  and  at  some  points  there  is  typical  liquefaction.  The  inner 
surface  of  the  cyst  has  no  epithelial  lining;  it  is  covered  with  blood  which  is  faintly 
organized. 

Number  of  Myomata  Removed  by  Abdominal  Myomectomy. — In  the  greater 
number  of  the  cases  the  uterus  contained  only  one  myoma,  and  that  was  inter- 
stitial. In  several  instances,  however,  several  tumors  were  enucleated.  For 
example,  in  U.  P.  I.,  S.,  and  C.  H.  I.,  H.,  9  myomata  were  removed.  In  Case 
4365,  10  myomata;  in  Cases  5153  and  10300,  11  myomata,  and  in  Cases  8773, 
6395,  and  5452,  13,  15,  and  17  myomata,  respectively,  were  shelled  out.  In 
Case  8462  (Fig.  318)  13  myomata  were  removed.  The  patient  six  years  later 
was  well.  The  greatest  numl^er  removed  in  any  one  of  our  cases  was  furnished 
by  Case  10351.  The  uterus  was  split,  and  28  myomata,  varying  from  1  to  1.5  cm., 
were  removed.  The  patient  developed  marked  abdominal  distention,  and  on 
exploration  free  blood  and  clots  were  found  in  the  abdomen.  Death  occurred 
on  the  fifth  day.     The  case  is  reported  fully  on  p.  537. 

After  adding  up  all  the  myomata  removed  and  then  striking  an  average, 
we  find  that  if  they  had  been  evenly  distributed,  each  uterus  would  have  con- 
tained a  fraction  over  two  m3'omata. 


Contraindications  to  Myomectomy. 

Low  Hemoglobin. — In  three  of  our  cases  in  which  abddiiiinnl  myoUHM'toiiiy 
was  performed  the  hemoglobin  was  very  low,  and  it  is  interesting  to  follow 
the  progi-ess  of  the  individual  cases. 

In  Case  9629  the  ])atient  was  twenty-seven  years  old  and  had  a  hemoglobin 
of  23  per  cent.  A  large  interstitial  myoma  nec(>ssilat(Ml  an  incision  into  the 
uterus  13  cm.  long.  The  patient  made  a  slow  convalescence,  owing  to  liei-  ;iiieinia, 
but  there  were  no  com})lications. 

In  Case  10573  the  patient,  aged  twenty-seven,  had  a  i-ougli  apical  systolic 
murmur  transmitted  laintly  to  the  axilla.     There  was  also  a  marked  systolic 
murmur  over  the  pulmonic  area;  hemogl()])in,  3S  per  cent.     A  myoma,  10  cm 
in  diameter,  and  several  smaller  ones,  were  emich^ateil.     '{'he  patient  develojxnl 
phlebitis  of  the  left  saphenous  vein  on  the  s(>venleenth  day.      It  did  not  retard 


518  MVOMATA    OF    THK    UTKRUS. 

her  progress  niatcriall}-.  liowever,  as  she  was  diseharged  on  the  twenty-fourth 
day. 

In  Case  10257  the  i)atient  was  twenty-three  years  old.  and  the  hemoglobin  47 
per  cent.  Prior  to  suspension  of  the  uterus  an  interstitial  myoma,  1  cm.  in 
diameter,  and  another  smaller  one,  were  removed.  Convalescence  was  normal, 
and  since  then  the  patient  has  had  two  normal  la})ors. 

Syphilis. — When  syphilis  exists,  the  question  naturally  asked  is,  Will  the 
wound  heal  if  an  abdominal  operation  is  jierformed?  In  Case  111G9  a  colored 
woman,  aged  fortj'-six,  had  marked  relaxation  of  the  outlet,  prolajisus  of  the 
uterus  and  a  myoma,  and  also  a  syphilitic  ulcer  of  the  leg.  The  cervix  was 
amputated,  the  perineum  repaired,  a  myoma  4  cm.  in  diameter  shelled  out  of 
the  fundus,  and  the  uterus  suspended.  The  patient  matle  a  perfect  recovery, 
and  was  transferred  to  the  surgical  department,  where  the  ulcer  was  skin-grafted. 
She  left  the  hospital  on  the  forty-seventh  day.  The  syphilitic  taint  in  this  case 
certainlv  in  no  wav  retarded  convalescence. 


Abdominal  Myomectomy. 

General  Considerations. — Before  undertaking  an  abdominal  operation  for 
uterine  myomata  several  points  should  be  thoroughly  weighed.  In  the  first  place, 
it  is  generally  agreed  that,  as  a  rule,  hysterectomy  is  safer  than  myomectomy. 
On  the  other  hand,  it  is  the  surgeon's  duty  to  save  the  pelvic  organs  whenever 
feasible. 

Age. — If  the  patient  is  under  forty-five  years  of  age,  the  possibility  of  a 
subsequent  pregnancy  should  always  be  borne  in  mind. 

Condition  of  the  Patient  . — ^^Tl(>n  the  })atient  is  very  anemic 
and  otherwise  frail,  as  a  rule,  a  myomectomy  is  hazardous,  antl  the  possible  gain 
by  saving  the  uterus  w^ould  be  more  than  balanced  by  the  liability  to  a  fatal  out- 
come. In  every  case  the  advantages  and  disadvantages  of  each  operation  should 
be  thoroughly  discussed,  and  explained  to  the  patient  or  some  responsible  relative. 

Under  no  circumstances  should  the  surgeon  undertake  the  operation  unless 
the  patient  freely  consents  that  the  operator  shall  do  exactly  what  he  deems 
wise  when  the  abdomen  is  opened,  as  it  is  usually  impossible  to  tell  with  absolute 
certainty  just  what  should  be  done  until  the  uterus  is  exposed.  One  patient 
coming  for  operation  was  so  strenuous  in  her  opposition  to  hysterectomy  that 
she  exacted  a  promise  from  one  of  us  (Cullen)  that  nothing  more  than  a  myo- 
mectomy should  be  done.  On  opening  the  abdomen  we  saw  clearly  that  hyster- 
ectomy would  be  the  safer  operation,  but  our  hands  were  tieil  by  the  promise, 
and  many  myomata  were  enucleated.  This  jjatient  (Case  10588),  within  twenty- 
four  hours,  developed  fever  and  died  at  the  end  of  forty-eight  hours.  There 
was  no  hemorrhage  into  the  abdominal  cavity,  ami  the  cultures  were  negative. 
Since  then  we  have  absolutely  refused  to  operate  unless  the  matter  is  left  to  the 
best  judgment  of  the  operator. 


ABDOMIXAL    .MY(  )M  KCTi  ).MY 


519 


Points  to  be  Considered  after  the  Abdomen  has  been  Opened. — As  soon  as  the 
uterus  is  exposed,  the  appendages  sliould  1)0  carefully  examined.  Should  pus- 
tubes  be  present,  it  will  be  necessary  to  remove  them  at  once,  and  if  this  can  be 
accomplished  without  the  escape  of  any  pus,  myomectomy  may  be  considered. 
Should  pus  escape,  however,  there  is  always  a  risk  of  infecting  the  cavities 
made  in  the  uterus  if  myomectomy  be  done. 

Next,  the  location  and  number  of  the  mj^omata  are  of  importance.  Sub- 
peritoneal and  pedunculated  nodules  are  eas}^  of  removal.  Interstitial  myomata, 
if  of  small  size  and  few  in  number,  are  also  enucleated  without  nuich  difficulty. 


Fig.  319. — Myo.mectomy  or  Hysterectomy. 
In  such  a  case  it  may  be  possible  to  shell  out  the  large  myoma  occupying  the  posterior  wall  and  the  several 
smaller  ones,  saving  the  uterus.  The  myoma  has,  however,  extended  so  far  downward  towartl  the  cervi.x  that 
it  would  have  been  very  difficult  to  accurately  close  the  myomectomy  wound.  Unless  the  patient  were  very 
young  and  the  necessity  for  children  of  the  utmost  importance,  hysterectomy  would  be  the  wiser  operative  pro- 
cedure, as  it  offers  the  patient  much  greater  cliances  of  recovery. 


It  has  Ix'cn  our  experience  thai  the  more  the  uterus  is  niulilatccl,  the  ui'catcr 
the  danger  to  the  palicul.  Where  many  interstitial  myoiiuita  are  removed, 
the  uterus  is  lacerated  in  all  directions,  and  it  is  not  only  diflicult  to  completely 
check  oozing',  but  the  area  I'oi'  infection  is  xci-y  ureat. 

The  same  applies  when  a  xcry  lai'iie  intei'stitial  myoma  is  enucleateil.  [''or 
example,  in  Case  4*)25  aji  interstitial  myoma,  12  x  21  x  27  cm.,  was  removed, 
and  .")()  catgut  sutures  were  re(|uii-e(l  to  obliterate  the  cavity  and  a]iproxlmate 
th(>  uterine  surfaces.  Notwitlistaiidinu,'  the  lad  that  our  patient  m.ade  a  ii;ood 
recovery,   in  future  we  would  liatilly  ad\'ise  such   an  ojx'i'ation  unless  the  j)()s- 


520 


MYO.MATA    OF    THE    UTERUS. 


sibility  of  issue  was  of  the  ^n-eatest  importance.     We  have  removed  myomata 
when  as  many  as  70  sutures  were  required  to  ol)hterate  the  cavity. 


If  the  cHnical  signs  strongly 
the  operator  should  be  exceedingly 
dominal  myomectomy.  Opening  up 
occasions  no    trouble,  as   noted   in 


My  oma    In 
post,  wall 


point  to  submucous  myomata, 
cautious  in  recommending  ab- 
the  uterine  cavity  sometimes 
Cases   5447  and  5493,  in  which 


Fig.  320. — The  First  Steps  i.\  .\i:i..j.\u\ai,  Mvomectomy. 

The  uterus  has  been  lifted  out  of  the  abdomen  ami  is  surrounded  with  gauze.     The  tubes  and  ovarie.s  are  normal 

The  myoma  m  the  posterior  wall  has  been  exposed  and  incised  for  a  short  distance. 

the  cavity  was  opened  up  for  its  entire  length.     It  is  sometimes  almost  impos- 
sible for  the  operator,  however,  to  tell   with   certainty   whether   the   endome- 


ABDOMINAL    MVU.MECTOMY. 


521 


/^l 


trium  is  normal  or  infected,  and  if  infected,  there  is  a  great  danger  that  the 
infection  may  spread  to  the  wound  in  the  uterine  wall. 

^^llen  large  interstitial  myomata  are  present  or  when  many  small  nodules 
are  found,  the  uterus  itself,  after  the  myomectomy,  is  occasionally  fully  tw(j  or 
three  times  its  natural  size;  consequently  the  tendency  to  aljsorption  is  maikcdly 
increased. 

In  Fig.  319  we  have  an  example  of  a  border-line  case — a  case  where  it  is 
difficult  to  determine  whether  a  myomectomy  or  a  hysterectomy  should  be 
performed.     The  uterus  contains  but  one  large  myoma,  and  this  does  not  ap- 
parently   encroach    u[)ou   the    uterine    cavity.     On    the    other 
hand,  it  extends  far   down    into    Douglas'    pouch,    and    after 
myomectomy  it  would  be  difficult  to  effectually  obliterate  the 
resultant  space.     In  this  case,  while  myomectomy  was  feasible, 
hysterectomy  as  carried  out  was  undoul^tedly  the  safer  proce- 
dure. 

Removal  of  Pedunculated  Myomata. — If  the  pedicle  is  ver}' 
small,  it  is  only  necessary  to  cut  it  in  such  a  way  that  in  the 
uterus  a  wedge-shaped  cavity  is  left.  If  there  are  any  large 
blood-vessels,  they  can  be  picked  up  free  hand  and  tied  with 
catgut  and  the  shallow  cavity  obliterated  with  catgut. 

Subperitoneal,  jiedunculated  myomata  are  occasionally  en- 
veloped in  omentum.  If  the  omental  adhesions  are  limited  to 
the  anterior  surface  of  the  myoma,  the  omentum  should  be  tied 
and  cut.  Care  should  be  exercised  because  such  omental  vessels 
are  often  very  large  and  friable,  and  if  torn,  bleed  tremend- 
ously. When  the  nodule  is  enveloped  in  adhesions,  it  is 
often  wiser  to  cut  the  pedicle  and  attack  the  adhesions  from 
the  under  surface. 

When  the  myoma  is  densely  adherent  to  the  sigmoid,  as  in 
Case  7978,  it  is  wise  to  sacrifice  the  outer  layers  of  the  tumor,     i,, 
leaving  them  attached  to  the  bowel.     In  (he  case  in  question  a 
thin  layer  of  tumor,   10  cm.  in  length,  was  left  on  the  bowel. 
After  removal  of  the  tumor  this  raw  ai'ea  was  turned  in  on  itself  ;uid  sutured, 
a  smooth  surface  resulting. 

Removal  of  Interstitial  Myomata, — The  removal  of  small  interstitial  myomata 
is  easy.  An  incision  is  made  over  them  (Fig.  320),  tiiey  are  grasped  with  the 
mesoforceps,  and  peeled  out  with  a  knife-handle  or  some  other  l)lunt  instrumtMit 
(Fig.  321).  Should  two  or  three  be  near  one  aiiothei-,  they  can  often  be  Ijrought 
out  through  the  same  incision,  thus  miniiiii/ing  the  possibility  of  sul)se(|uent  ad- 
hesions. 

When  a  large  interstitial  myoma  is  |)i'esenl .  an  o\'al  or  ellii)lic  incision  is 
usually  made  over  tiie  tumoi-.  It  is  alwavs  better  to  be  on  tiie  safe  side  and 
not  remove  too  large  an  area  of  the  uterine  wall  with  the  mvoina,  as  after  removal 


C'i-i,ij:n'    Myoma 
Enucleator. 


522  .MYOMATA    OF   THE    UTERUS. 

of  the  iiiyonia  the  uterine  muscle  frequently  ivtracts  to  such  an  extent  that  it  is 


Fig.  322. — Shelling  the  Tumor  Out  or  the  Uterine  W.\ll. 
The  myoma  is  firmly  grasped. with  the  mesoforceps  and  strong  traction  made.     The  tumor  is  being  shelled  out  by 

means  of  the  myoma  enucleator. 

difficult  to  bring  the  tissues  together  and  obliterate  the  dead  space.     On  the 
other  hand,  it  is  easy  to  cut  away  the  excess  from  redundant  uterine  flaps. 


ABDOMINAL    .MYUMECTO.M V. 


523 


The  myoma  is  grasped  with  a  strong  mesoforccps  and  gradually  shelled  out 
with  a  myoma  enucleater  (Fig.  322),  a  pair  of  curved  artery  forceps,  a  knife- 
handle,  or  a  bhiut  periosteal  elevator.     Care  should  be  taken  to  avoid  getting 


Fig.  8  5titch  closing  wound 


Fig.  323.— Dbliteuation  ok  the  Space  in  the  Uteiu.ne  Wall  ai  ii,k  Ixi-nka  al  ok  the  .Mm>ma. 
One  figure-of-8  catgut  suture  has  been  introduceil  and  tied.     The  second  has  just  been  inserted.     It  is  impor- 
tant to  accurately  coapt  the   surfaces,  leaving   no  dead  spaces.     Whon    llic  cavity  is   large,  two  or   throe  tiers  of 
sutures  may  be  necessary  in  aildition  to  tying  any  large  vessels. 

into  the  uterine  cavity,  it'  po.s'^ihle;  hut ,  wliei'e  neces.siiy,  il  may  he  fully  ()pene(l 
up. 

Submucous  Myomata.  .Many  large  inteistilial  niyoin.ala  are  partly  submucous, 
and  then  it  may  be  necessarx'  to  hi-ing  away  a  iai'ge  area  of  llie  muco.sa  covering 
the  mvoma.     This  should   he  cut    awav   boldly   but    eai-efully   with    the   knife. 


524 


.MYOMATA    OF    THE    ITERUS. 


Sometimes  where  there  is  marked  utei'ine  hemorrhage  but  a  small  uterus,  hyster-- 
otomy  is  done,  the  first  incision  going  directly  into  the  uterine  cavity.  This  is 
then  explored  for  small  myomatous  nodules,  which  often  give  rise  to  alarming 
hemorrhage. 

If  the  uterine  cavity  is  oi)ened,  after  the  removal  of  large  nodules  it  is  usually 
wise  to  dilate  tiie  cervix  from  al)ove  to  allow  for  free  drainasje  for  several  davs 


Fig.  324. — Appe.\r.\nce  of  the  Uterus  after  Abdomix.m.  Myomectomy. 
The  uterus  is  still  considerably  enlarged.     Accurate  approximation  has  been  accomplished.     By  employ- 
ing a  figure-of-8  suture,  only  half  as  many  knots  are  necessary,  and  thus  there  is  a  diminished  liability  to  ad- 
hesion. 

at  least.  Whether  a  small  <raii/.e  drain  should  he  left  in  tiie  uterus  with  its  low 
end  projecting  from  the  cervix  is  still  a  mooted  question.  We  have  em])loyed 
it  in  several  cases. 

The  sutures  are  now  introduced  into  the  depth  of  the  wound.  They  extend 
to,  but  do  not  ])ierce,  the  mucosa.  When  these  are  tied  the  uterine  cavity  is 
closed. 


ABDOMINAL   MYOMF.CTOMY.  o2a 

In  the  early  days  we  employed  silk,  but  now  catgut  is  used  in  all  niyoniecto- 
niies.  The  cavity  in  the  uterine  wall  is  gradually  obliterated  with  tier  after  tier 
of  figure-of-eight  catgut  sutures  (Fig.  323)  introduced  with  a  curved  needle  with 
rounded  edges,  and  finally  the  surfaces  of  the  uterus  are  approxiinate(l  as  ac- 
curately as  possible,  and  yet  with  just  sufficient  pressure  to  check  bleeding  (Fig. 
324).  Ochsner  lays  special  stress  on  not  tying  the  sutures  too  tight,  as  the 
tissues  may  be  so  blanched  that  they  become  incapable  of  resisting  the  slightest 
infection.  One  must,  however,  completely  obliterate  the  spaces  formerly  occu- 
pied by  the  myomata. 

Tearing  of  the  Uterine  A  r  t  e  r  y  d  u  r  i  n  g  A  b  d  o  ni  i  n  a  1 
Myomectomy  . — In  Case  6773  both  ovaries  were  released  from  light  ad- 
hesions, and  two  interstitial  myomata,  each  about  4  cm.  in  diameter,  removed. 
One  of  the  tumors  lay  very  close  to  the  uterine  artery.  This  vessel  was  torn 
during  the  enucleation  and  ligated  near  the  cervix.  The  uterus  was  then  sus- 
pended. 

Suspension  of  the  Uterus  after  Myomectomy. — One  of  the  greatest  drawbacks 
to  a  myomectomy  is  the  fact  that  one  or  several  lines  of  sutures  are  bristling 
from  the  surface  of  the  uterus  and,  so  to  speak,  are  inviting  the  omentum  or 
intestine  to  become  adherent.  If  the  suture  line  be  in  the  anterior  wall  of  the 
fundus,  it  can  be  effectually  hidden  by  attaching  the  uterus  to  the  anterior 
abdominal  wall.  If  fastened  to  the  anterior  wall,  firmer  union  is  liable  to  take 
place  than  if  no  myomectomy  had  been  performed,  and  a  subserjucnt  pregnancy 
may  lead  to  serious  trouble,  as  in  Case  4856  (p.  567).  If  the  uterus  is  suspended 
with  catgut  instead  of  silk,  the  union,  as  a  rule,  is  not  so  firm.  In  any  event  we 
would  infinitely  rather  take  the  chances  of  dystocia  than  of  intestinal  obstruction 
from  adhesions,  especially  when,  at  any  time  during  the  course  of  a  subsequent 
pregnancy,  by  a  very  simple  exploratory  laparotomy,  the  adherent  uterus 
may  be  readily  freed,  as  has  recently  been  pointed  out  by  Dr.  Elizalx'th  Ilurdon* 
and  others. 

Covering  o  v  e  r  t  h  e  1  ]i  c  i  s  i  o  n  i  n  the  It  c  r  u  s  w  i  t  h  the 
Broad  L  i  g  a  lu  c  ii  t  .  When  the  tissues  are  lax,  it  may  be  possible,  as  was 
done  in  Case  12852,  to  draw  portions  of  the  bi'oad  ligaiiicnt  o\-ci-  the  fundus, 
thus  completely  hiding  the  suture  line. 

Preservation  of  a  Portion  of  the  Fundus.  W  hen  the  niyonia  occupies  nearly 
the  entire  fundus,  )-endering  an  enucleaiioii  dillicuh,  it  may  still  be  possible,  by 
am{)utation,  to  save  a  portion  of  the  nuicosa.  This  plan  was  adopted  in  cases 
C.  H.  1.  930  and  in  C.  11.  I.  1019. 

In  Case  C.  H.  I.  1019  the  patient  was  ihiity-nine  yeai's  old.  The  ni(>nses 
continued  for  six  months  and  then  ceased.  Since  then  ihe  patient  has  been 
in   bed  nearly  all  the  time,  suffering  from  mnikeil  cnidiac  dilalalion. 

In  Cas(>  C.  H.  I.  930  the  I'esults  have  been  much  more  salislactoiy.  The  up])ei' 
part   ot   the  fundus  was  amputated  on  accouni   of  a  subnnicous  myoma,  7  cm. 

*  Aiiifricaii  Joiir.  of  Ohst dries,  .Julv,  I'.IOT. 


526 


MYOMATA    OF   THE    UTERUS. 


in  diameter.    Tiie  i)atieiit,  fifteen  months  later,  was  in  good  health  and  menstru- 
ating regular!}'. 

This  method  of  atteni])ting  to  save  as  much  of  the  mucosa  of  the  body  as 
feasible  has  received  a  great  deal  of  attention  from  Spinelli,  of  Naples,  and 
others,  and  deserves  the  most  careful  consideration. 

Other  Operations  Performed  in  Conjunction  with  an  Abdominal  Myomectomy. 
When  the  patient  is  under  the  anesthetic,  other  pathologic  pelvic  conditions 
requiring  attention  are  often  detected.     The  accompanying  data  will  give  a  fair 
idea  of  the  various  other  operations  that  were  performed  in  the  296  abdominal 
mvonicctomv   cases: 


Removal  of  both  tul)es  and  ovaries 13  cases 

Removal  of  rijjht  tube  and  ovary 11       " 

Removal  of  left  tube  and  ovary 12       " 

Removal  of  one  or  both  tubes 18       " 

Plastic  operations  on  the  tube 3       "    (Nos. 

Release  of  pelvic  adhesions 17       " 

Removal  of  ovarian  cysts 20       " 

Graafian  follicle  cysts:   Cases  4765,  8698,  C.  H.  I.  Peth.,  5493  and  12848. 
Corpus  luteum  cysts:   Cases  5588,  C.  H.  I.  Cuth.,  C.  H.  I.  930,  San.  1628. 
Papillocystoma  of  ovary:   Cases  1455,  12034  (double). 
Dermoid  cyst:   Case  12852  (left  twisted  pedicle),  San.  2142. 

Resection  of  corpus  fibrosum 1  case 

Repair  of  perineum 37  cases 

Repair  of  complete  perineal   tear 2       " 

Anterior  colporrhaphy 5       " 

Removal  of  vaginal  cysts 2       "    (Nos, 

Dilatation  and  curetting 28       " 

Amputation  of  cervix 10       " 

Suspension  of  uterus 71       " 

Shortening  of  the  round  ligaments 6       " 

Appendectomy 15      " 

Cure  of  left  inguinal  hernia 1   case 

Cure  of  ventral  hernia 1       " 

Cholecystotomy  (for  gall-stones) 2  cases(Nos. 

Fixation  of  kidney 2       " 

Opening  of  ischiorectal  abscess 1  case 

Removal  of  hemorrhoids 3  cases 

Removal  of  clitoris 1  case  (No. 

Omphalopexy 1      "    (San. 


4016 

4471 

12165). 


5846 

8844). 


6854 
8310). 


9304). 
1545). 


Tubes  and  Ovaries. — The  removal  of  the  tubes  and  ovaries  was  indicated  in 
most  instances  by  dense  adhesions,  hydrosalpinx,  hematosalpinx,  or  pus  tubes. 

In  Case  9243  the  right  tube  was  the  seat  of  a  tubal  ]iregnancy,  and  in  Case 
10587  the  mucosa  of  both  tubes  was  tuberculous. 


ABDOMINAL    MYOMIXTOM Y.  o2i 

Plastic  opt' rat  ions  were  dune  uii  the  left  tube  in  Case  4471,  and  on  the  right 
tube  in  Case  4016,  artificial  fimbriated  ends  being  made. 

In  Case  12165  a  myoma  occupied  the  cornii,  and  after  removal  of  the  tumor 
the  tube  was  anastomosed  into  the  uterine  wall  with  success. 

Ovarian  C  y  s  t  s  . — Where  feasible,  small  ovarian  cysts  were  merely 
punctured  or  resected,  as  much  of  the  ovary  as  possible  being  saved. 

It  will  be  noted  that  in  two  instances  (Cases  1455  and  12034)  secondary 
papillary  masses  were  scattered  throughout  the  abdomen. 

Gyn.  No.  1455. 

A  b  d  o  m  i  n  a  1  I\I  y  o  m  e  c  t  o  m  y  a  n  d  Removal  of  P  a  p  i  1 1  o  - 
c  y  s  t  o  m  a    o  f    the    Ovary. 

H.  J.,  married,  aged  fifty-seven,  white.  Admitted  June  27;  discharged 
August  8,  1892.  Operation:  When  the  abdomen  was  opened,  a  large  cyst  was 
tapped.  It  had  developed  from  the  right  ovar}^,  and  contained,  besides  2000  c.c. 
of  chocolate-colored  fluid,  many  dense  papillary  masses.  The  peritoneum  was 
also  studded  with  ])apillary  masses.  A  pedunculated  myoma  attached  to  the 
left  uterine  cornu  was  enucleated.  The  patient  made  a  satisfactory  recov(>ry. 
On  June  10,  1907,  we  received  a  communication  from  the  patient's  husband 
saying  that  she  had  died  on  September  11,  1903;  in  other  words,  she  had  li\('d 
eleven  years,  notwithstanding  the  fact  that  papillary  masses  were  i)resent  at 
the  time  of  operation. 

Gyn.  No.  12034. 

Bilateral  P  a  p  i  1 1  0  c  y  s  t  o  m  a  t  a  of  the  0  v  a  r  y  w  i  t  h  m  u  1  - 
t  i  p  1  e  Metastases  in  the  Peritoneum  and  Bowel.  A  b  d  o  - 
m  i  n  a  1     M  y  o  m  e  c  t  o  m  y  . 

This  patient  was  admitted  April  8,  and  discharged  May  5.  1905.  At 
operation  about  2000  c.c.  of  ascitic  fluid  were  evacuated,  and  both  ovaries  were 
found  to  be  the  seat  of  papilkuy  cysts.  The  one  on  the  Ict'l  side  was  a])i)roxi- 
mately  13  cm.  in  (liaiuclci';  the  one  on  the  i-Juht .  sdiiicwhat  smaller.  Projecting 
from  the  surface  were  delicate,  tree-like  .outgrowths.  These  covennl  over  half 
the  surface  area  of  the  cyst.  The  cysts  and  a  myoma.  2.5  cm.  in  diameter. 
were  removed.     The  patient's  health  a  year  and  a  half  later  was  "tairly  good." 

in  both  of  these  cases,  after  removal  of  the  o\arian  tumors  a  myomectomy 
was  done.  Under  ordinary  circumstances  one  would  prefer  hysterectomy,  but 
in  both  of  these  cases,  as  intlicated  ])y  the  history,  myomectomy  under  existing 
circumstances  was  a  simpler  operation,  ll  is  remarkable  that  in  Case  1455 
the  patient  lived  over  ten  years  after  th(>  oj)eration.  notwithstanding  the  wide 
distribution  of  ihe  |i;i|iill;iry  ,u-r((\\tli. 

Repair  of  the  Perineum.  4'lie  large  number  of  jierineal  o])erations  was  in- 
dicated mainly  by  the  numerous  cases  of  jn'olapsus  a.'^sociated  with  myomata. 


528  MYOMATA    OF   THE    UTERUS. 

Suspension  of  the  Uterus.  It  will  be  seen  from  the  t;il)k'  that  in  71,  or  nearly 
25  per  cent,  of  the  cases,  the  uterus  was  suspended.  This  was  clone  partly  for  the 
correction  of  a  retrodisplacenient,  but  more  often  on  account  of  the  necessity 
of  bringino;  the  myomectomy  suture  line  in  contact  with  the  anterior  abdominal 
wall,  thus  minimizing  the  possibility  of  the  omentum  or  intestines  becoming 
adherent  to  the  catgut  sutures    ])rojecting   from    the   surface    of    the   uterus. 


Abdominal  Myomectomy  During  Pregnancy. 

^^'hen  a  myoma  complicates  pregnancy,  no  operation  is  performed  until  after 
delivery,  providetl  the  myoma  in  no  way  obstructs  the  pelvis,  so  as  to  prevent 
delivery  by  the  vagina.  In  six  of  our  cases,  for  various  reasons,  it  was  deemed 
necessary  to  do  a  single  or  nuiltiple  enucleation  during  the  puerperium.  In 
Case  4990  the  patient  had  had  four  miscarriages,  but  no  children  at  term,  during 
her  seven  years  of  married  life.  On  her  admission  she  was  three  and  one  half 
months  pregnant.  An  interstitial  and  partly  submucous  myoma,  7  x  7  x  10  cm., 
was  removed  (Fig.  325),  but  one  in  the  cervical  region  could  not  be  dislodged 
without  much  handling  and  the  certainty  that  a  miscarriage  would  be  caused. 
Xotwithstanding  the  extreme  care  the  fetus  came  away  on  the  tenth  day. 
About  seven  weeks  after  the  first  operation  the  cervical  nodule,  which  measured 
10  cm.  in  diameter,  was  shelled  out. 

Case  5081  affords  another  example  of  a  miscarriage  following  myomectomy. 
The  patient  was  three  mouths  pregnant  (Fig.  326).  An  interstitial  myoma, 
8  X  9.5  x  12  cm.,  was  removed.  Within  twenty  hours  the  patient  complained 
of  sudden  uterine  pain,  and  the  fetal  head  was  found  projecting  from  the  vulva. 

The  results  in  the  three  succeeding  cases  were  much  more  satisfactory,  the 
pregnancy  in  each  of  these  cases  going  on  to  term.  In  Case  1249  the  patient  was 
three  months  pregnant.  A  sessile  subperitoneal  myoma,  about  6x7x8  cm., 
was  removed  from  the  posterior  surface  of  the  uterus  (Fig.  327)  and  recovery 
was  uninterrupted. 

The  patient  in  Case  8897  had  been  pregnant  over  three  months.  A  pedun- 
culated myoma,  8  x  8  x  12  cm.,  was  removed  from  the  left  side  of  the  uterus,  and 
two  interstitial  nodules,  each  2  cm.  in  diameter,  were  shelled  out.  The  preg- 
nancy went  to  term. 

Mrs.  G.  (Path.  No.  7895)  was  brought  to  the  Emergency  Hospital,  Frederick, 
complaining  of  uterine  hemorrhages.  A  cystic  mass  could  be  felt  rising  out  of  the 
pelvis.  Pregnancy  w-as  suspected,  but  the  operator  w^as  assured  that  none  ex- 
isted. As  will  be  noted  from  Fig.  328,  a  myomatous  tumor  occupied  the  anterior 
lip  of  the  cervix  and  encroached  markedly  on  the  anterior  vaginal  wall.  On 
opening  the  abdomen  a  four  months'  pregnancy  was  found.  The  myoma  was 
shelled  out  from  above,  and  an  area  of  vaginal  mucosa,  6x5  cm.,  removed  with  it, 
as  the  myoma  was  very  adherent  to  the  vagina.     The  patient  })romptly  recovered. 


ABDOMINAL    M  YO.M  KCTo.M  V.  529 

and  was  (l('li\-ci-('(l  at  tcnii  of  a  tt'ti-pouiid  cliilil.  In  this  case  the  inyonia  so 
obstnictcil  tlic  ])('l\is  that  a  iioi'inal  labor  would  hardly  havo  been  possil)le. 

^^\'  had  oiu'  (^('asc  11110)  death  following  niyomectoniy  during  pregnancy. 
This  patient  had  been  married  eleven  years  and  had  never  Ijeen  jjregnant.  A\'hcn 
the  abdomen  was  ojx'iied  a  large,  soft,  four  months'  pregnancy  was  found. 
Scattered  over  the  surface  were  many  small  myomatous  nodules.  The  largest, 
7  cm.  in  diameter,  was  removed.  Considerable  difficulty  was  experienced  in 
controlling  the  hemorrhage.  After  the  operation  the  bowels  would  not  move. 
On  the  fifth  day  the  fetus  was  expelled,  and  the  placenta  had  to  be  removed  with 
the  curet.  On  account  of  an  intestinal  obstruction  enterostomy  was  performed, 
on  the  sixth  day.  There  was  much  bloody  fluid  in  the  abdomen,  Init  the  intestines, 
apart  from  the  distention,  looked  normal.  The  patient  died  on  the  follo^^ing 
day.  This  case  is  reported  in  full  on  p.  530,  und(>r  "  Deaths  following  abdominal 
myomectomy." 

In  Oase  650S  al)dominal  myomectomy  was  attempted  during  pregnancy, 
but  on  account  of  the  excessive  hemorrhage,  an  immediate  Porro  operation 
seemed  imjierative. 


Detailed  Report  of  Cases  in  which   Abdominal  Myomectomy  was  Performed 

DURING  Pregnancy. 

Gyn.  No.  4990.     Path.  Nos.  1521  and  1628. 

U  t  e  r  i  n  e  M  y  o  m  a  t  a  Complicating  a  t  h  r  e  e  a  n  d  a  h  a  1  f 
m  o  n  t  h  s  '  pregnancy   (Fig.  325). 

M.  S.,  married,  aged  thirty-five,  white.  Admitted  February  3;  discharged 
April  24,  1897.  The  patient  has  been  married  seven  years,  has  had  no  children, 
l)ut  four  miscarriages,  the  last  two  years  ago.  In  December,  1S9G,  she  discoveretl 
a  small  hard  lump  in  the  right  side  of  the  abdomen,  low  down. 

Operation,  myomectomy.  To  the  right  of  the  three  and  one  half  months' 
pregnant  uterus  was  a  dense,  hard  myoma,  which  was  lii-mly  attached  to  the 
uterus  (Fig.  325).  There  was  also  a  large  myoma,  situated  low  down  in  the  broad 
ligament,  to  the  left  of  the  cervix.  The  one  on  the  right  side  was  removed, 
but  it  was  impossible  to  remove  the  one  in  the  Nroad  ligament  without  iiUer- 
fering  with  the  pi-cgnancy.  Ten  days  later  the  paliciU  miscarried,  and  it  was 
necessaiy  to  i-emo\-e  the  I'emains  of  the  placenta  with  the  curet. 

March  15,  1S97:  An  attem]>1  was  made  to  i)artially  obliterate  the  Moo.l- 
supply  of  the  utei-us  by  clamping  Uic  left  utei-iiie  vessels;  but  this  had  little  el'fect. 

March  27,  bS97:  Myomectomy  per  abdomeiu  The  lai'ge  inyonia  situated  to 
the  left  of  the  cervix  was  renioveil.  The  ))atient  made  an  unintci-i-uptcd  i-ecoNcrv. 
It  is  intei-esting  to  note  that  the  site  of  the  lli'sl  niyonii'cNuny  was  almost  uiu'cc- 
Ognizable  at   the  second  operatioiL  llierr  heing  praci  jcalK'  no  seal'. 

Path.  .\o.    1521.     The  myoma  situated  ncai'  ihc  right   lulie  nicasure(l  7x7 
X  10  cm. 
34 


530 


MYOMATA    OF    THE    UTERUS. 


Fig.  325. — Uterine    Myomata    Complicated 
BY    A    Three    .\nd    one-h.\lf     Months' 
Pregnancy. 
Gyn.  No.    4990.     The   interstitial    myoma 

near  the  right    tube    was    enucleated.     A   mis- 


Path.  \().  1()2S.  The  iiiyonia  situated  to  the  left  of  the  cervix  was  10  cm. 
in  (liaineter. 

Jaiuiarv  1,  1007.     T]\v  patient 's  jreneral  health  at  present,  nearly  ten  years 

after  operation,  is  ijood.  She  has  no  hemor- 
rhages. .Menstruation  is  normal.  There  has 
been  no  {jregnancy  since  the  operation. 

Gyn.  No.  5081. 

V  t  ('  r  i  n  (■  -M  y  o  in  a  t  a  C  o  m  p  1  i  - 
c  a  t  i  n  o;   P  r  e  g  n  a  n  c  y    ( Fig.  826). 

R.  H.,  nian-ied  seven  months,  aged 
twenty-five,  white.  Admitted  March  9: 
discharged  May  2.").  1S97.  Operation.  An 
interstitial  myoma,  8x9.5x12  cm.,  was 
removed  (Fig.  .326).  The  incision  into  the 
uterus  was  14.5  cm.  long,  and  the  hemor- 
rhage was  excessive.  Two  other  small  myo- 
mata were  also  remo\'ed.  The  patient  was 
kept  under  mor])hin  after  operation,  l)ut 
within  twenty  hours  c()m])lained  of  sudden 

carriage  followed   on  the  tenth  day.     The  large        p.^^jj^   .^^^^\  ^^j^.    fV^.^J    \-^^..^^\   ^y^g   fouud   l)rojeCt- 
nodule  to  the  left  of  the  cervix  was  removed  _ 

several  weeks  later.  iug  fi'om  the  vulva.     She  was  anesthetized 

and  a  three  months'  fetus  and  })lacenta  were 
removed.     The  subsequent  history  was  uneventful. 

A  letter  from  the  patient,  dated  January  1.  1907,  nine  and  one-half  years 
after  operation,  states  that  she  has 
been  under  a  physician's  care  for 
uterine  trouble  for  four  years.  She 
has  no  hemorrhages.  There  is  no 
vaginal  discharge,  but  there  is  some 
bladder  irritation.  Her  menses  are 
normal. 

Gyn.  No.  1249. 

M  y  o  m  e  c  t  0  111  y  Without 
I  n  t  e  r  f  e  r  e  n  c  e  w  i  t  h  the 
Pregnane  y    ( Fig.  327). 

M.  S.,  married,  aged  twenty-five. 
Admitted  March  7:  discharged  April 
6,  1S92.  The  i)atient  has  b(>en  mar- 
ried one  year,  and  has  had  110  chil- 
dren and  no  miscarriages.  Operation,  myomectomy.  .\n  incision,  8  cm.  in 
length,  was  made  into  the  uterus,  and  the  .subperitoneal  noelule  projecting  from 


Fu;.  326. — .Mlltipi.k  .M  vu.MKtioMY  on  a  Wo.man  Three 
Mo\TH.s  Pregn.^nt. 
Cjyn.  No.  .5081  The  large  interstitial  myoma  pro- 
jected from  the  posterior  surface  of  the  uterus.  It  was 
enucleated,  and  several  smaller  nodules  were  also  re- 
moved. .\  miscMTiage  followed  within  twenty-four 
hours. 


AHDO.MINAL    MYOMECTOMY. 


531 


the  posterior  surface  removed  (Fig.  327J.  Tliis  luyoiiia  was  ap])roxiinately 
7x6x8  em.  The  temperature  never  rose  above  99.5°  F.  The  patient  made 
a  perfect  recovery,  and  tlie  pregnancy  went  on  to  term. 

January  1,  1907.  about  fourteen  and  one-half  years  after  operation :  A  h'tter 
from  Dr.  Edwin  II.  MiUer.  of  Philad('l))hia.  states  that  the  patient's  general 
heahh  is  not  good.  She  has  no  hciiion-hagcs;  there  is  no  (hscharge;  no  bladder 
disturbance,  and  her  menstruation  is  normal. 


Gyn.  No.  8897. 

U  t  e  ]•  i  n  e    M  y  o  m  a    C  o  m  ]>  1  i  c  a  ting    P  r  e  g  n  a  n  c  y  . 

K.  S..  aged  twenty-nine,  white,  marrieti.  Admitted  July  o:  discharged  Julv 
;>(),  1901.  The  ])atient  has  been  mar- 
ried six  months.  ()n  bimanual  exam- 
ination definite  myomatous  nodules 
can  be  made  out.  Operation,  nuiltiple 
niyomectoni}'.  A  median  incision 
exposed  one  large  myoma  springing 
from  the  wall  of  the  fundus  an- 
teriorly, a  smaller  one  beside  this 
on  the  anterior  wall,  and  a  third  on 
the  left  posterior  wall.  The  pedicle 
of  the  large  myoma  was  cut  across, 
and  the  resultant  raw  surface  obliter- 
ated with  catgut  sutures.  The  other 
two  myomata  were  shelled  out.  The 
uterus  itself  was  about  the  size  of  a 
fourmonths'  pregnancy.  The  patient 
recovered  raj)i(lly.  the  pregnancy  be- 
ing in  no  way  interfered  with.  The  large  myoma  measured  S  x  S  \  12  cm.:  the 
two  smaller  ones,  each  2  cm.  in  diameter. 

Case  G.,  Path.  No.  7895. 

•^  <■  "1  o  \  a  1  of  a  Large  Cervical  Myoma  per  Abdomen 
f  r  o  m   a    P  :i  t  i  e  11  t    I-'  o  u  r   .M  o  n  t  h  s    P  r  e  n;  n  ;i  n  t    ( l-'iti;.  M2S). 

This  p;itii'nt  \v;is  I  hli-ly-foui'  \'e;irs  of  .me.  ( )ne  of  us  (('.)  saw  her  in  coiisuMa- 
tionwith  Dr.  Lamar,  of  .Middletown.  on  .May  17.  P.IOI.  She  was  o|)er;ited  U|)on  in 
tile  Frederick  I'lmergency  Ilospitnl.  She  h;id  been  hieeding  profusely  for  several 
weeks.  When  1  saw  liei-,  the  pulse  \v:is  j.'lO.  The  eiit ire  anterior  lijt  of  the  cervix 
was  greatly  thickened  (  |''i<r.  :\2Sr.  the  |)osterior  was  noi-m.-ij.  The  ihickening  in 
the  anterior  cervic:il  lip  w.-is  c;iused  by  ;i  h.-ird  nodule,  approximately  '.)  cm.  in 
diameter,  .\bove  this  was  \\h;it  ;ippe;ired  lo  be  a  cystic  tumor.  Despite  care- 
lul  in(|uiries  there  was  nothing  in  the  histor\-  in  any  way  suggesting  pregnancy. 
On  opening  the  abdomen  we  found  ;i  foui-  months'  pregn.'incy  and  the  ni\-oma  of 


Fig.    327. — A    Subpekito.ne.^l    .My(j.\i.\    Complicating 

PrEGN'.'VNCY. 

Gyn.  No.  1219.     The  subperitoneal  nodule  (m)  was  enu- 
cleated and  the  patient  went  on  to  temi. 


532 


MVU.MATA    OF    THK    ITKRUS. 


the  anterior  lip.  This  almost  completely  filled  the  })elvis.  Not  having  per- 
mission to  do  a  hysterectomy,  we  determined  to  shell  out  the  myoma,  but  this 
was  so  intimately  hlcndcd  with  the  vaiiina  that  a  jiortion  of  the  vagina,  a])out 
6x5  cm.,  had  to  he  ri'moved  with  the  tumor.  The  o])eiiing  into  the  vagina  was 
dosed,  but  there  was  nmch  oozing,  and  in  places  the  bleeding  was  checked  with 
the  greatest  difficulty.  The  patient  made  a  good  recovery,  went  on  to  term, 
and  after  a  normal  labor  was  delivered  of  a  ten-pound  child. 


Fig.  328. — Myoma  of  the  Cervix  Obstkucting  the  Vagina  and  Complicating  a  Four  Months'  Pregnancy. 
G.,  Frederick  Emergency  Hospital,  Path.  No.  7895.  The  myoma  had  developed  in  the  outer  portion  of  the 
anterior  lip  of  the  cervix.  It  ha<l  not  only  grown  upward,  but  also  had  encroached  markedly  on  the  vagina.  It 
was  so  intimately  blended  with  the  vaginal  mucosa  that  over  a  wide  area  it  was  necessary  to  remove  the  mucosa 
with  the  myoma.     The  pregnancy  proceeded  to  term. 

On  -May  2!),  l',)()7,  three  years  after  the  operation,  I  received  a  letter  from  the 
patient  in  which  she  stated  she  was  al)Solutely  well. 


Immediate  Death  Following  Abdominal  Myomectomy. 
In  our  29(3  al)(lominal  myomectomies  2<S()  ])atients  recovered  and  1(3  died — a 
mortality  of  5.4  jK-r  cent.     From  the  clinical  course  of  the  fatal  cases  and  from 
the  autopsy  findings  in  .^ome  of  tliem  we  can.  with  a  fair  degree  of  accuracy, 
divide  the  probable  causes  of  death  into  the  following  grouj)s: 


ABDOMINAL    M  YO.M  i;(  T(  ).M  Y.  533 

Intestinal  obstruction,  peritonitis,  or  hotli 8  cases 

(Cases    57,   65,   4S2,    1862,    563S,    7560,    10351.     S;  Toronto   case.) 

Possible  cerebral  embolus  with  hyperpyrexia 1  case 

Myomectomy  during  pregnancy 1      " 

Probable  infection  from  an  unsuspected  carcinoma  of  tlie  body  (Case  1173)  1      " 

Probable  death  from  faulty  catgut  (Case  1752) 1      " 

Probable  infection  from  Fallopian  tube  (Cases  5124  and  11296) 2  cases 

Almost  moribund  condition  of  patient  before  operation,   deatli  on  table 

(Case  1672) , 1  case 

Possible  myocarditis  (C.  H.  I.,  W.)  1      " 


16  cases 


Intestinal  Obstruction,  Peritonitis,  or  Both. 

In  the  majority  of  our  fatal  cases  death  was  due  either  to  intestinal  obstruc- 
tion or  peritonitis  or  to  obstruction  followed  by  peritonitis.  In  some  instances 
the  cause  of  death  is  perfectly  clear,  as  in  Case  7560,  in  w^hich  the  patient  un- 
doubtedly died  of  a  streptococcus  peritonitis.  In  other  cases,  however,  the 
patients  had  first  shown  signs  of  intestinal  obstruction,  and  later  mild  manifesta- 
tions of  peritonitis.  It  is  well  known  that  obstruction  may,  in  a  few  days,  lead 
to  peritonitis,  and,  further,  that  where  peritonitis  is  the  primary  factor,  intestinal 
paralysis  with  signs  of  ol^struction  is  among  the  earliest  manifestations  of  i)eri- 
tonitis.  We  are  inclined  to  think  that  in  our  cases  intestinal  obstruction  was  the 
dominant  factor  in  most  instances,  and  that  the  peritonitis  was  secondaiy. 

As  we  all  learn  more  ])y  our  failures  than  by  our  successes,  we  have  concluded 
to  report  each  of  the  fatal  cases  in  some  detail,  so  that  the  reader  may  draw  his 
own  conclusions  as  to  the  cause  of  death. 

Gyn.  No.  57. 

Abdominal    M  y  o  m  e  c  t  o  m  y  ;    Obstruction;    Death. 

S.  R.,  married,  aged  thirty-three,  colored.  Admitted  November  L\') ;  died 
December  6,  1889.  Oi)eration,  uiyoincctoiny ;  double  sal|)iii,u()-()(')jtli()rectomy. 
A  myoma,  3.5  cm.  in  diameter,  was  removed  from  the  fundus.  Both  tubes  and 
ovaries  were  excised  on  account  of  adhesions,  .\fter  operation  the  abdomen  was 
not  distended  or  tynii)anitic.  X'omiting  connneneed  on  the  tliii'd  day.  There 
was  inabihty  to  evacuate  the  bowels  after  the  sixth  day.  The  |)atient  die(l  on 
the  eleventh  day.  Iler  |)ulse  at  that  time  reached  HIS;  hei-  temperature  was  not 
over  100.5°  F.     Just  |)i'ioi'  to  death  there  was  .some  delii'iuiiL 

Aut.  No.  48.  ^riie  ])ei-iloiieum  is  red  and  injected.  The  intestines  are  ad- 
herent, and  bound  down  in  the  peKis.  The  heait  and  lungs  ai'e  normal.  Cul- 
tures from  the  peritoneal  caNil)'.  kidne\s,  and  sjileeii  gixc  negatixc  I'esults. 

Gyn.  No.  65. 

Intestinal  ( )  b  s  t  i-  u  c  t  i  o  n  !•'  o  1  I  o  w  i  n  g  .\  b  d  o  m  i  11  a  1  .M  y  - 
o  m  e  c  t  o  111  \-  .       Death. 


534  MYOMATA    OF    THK    UTERUS. 

V.  K.  H.,  inarricil.  :i<i;(>(l  tliirty-thrco.  ^vhito.  Admitted  ])ec-cniber  10,  1889; 
died  Jamiarv  2.  ]8!)().  Operation.  December  30th.  The  pelvis  was  filltMl  with 
the  tumor  mass,  which  was  intimately  adherent.  After  li!)eration  of  adhesions, 
which  was  accom])anied  by  considerable  hemorrhage,  a  myoma  was  enucleated, 
the  uterine  cavit}'  beinij;  o])ened. 

8ul)se{iuent  History. — The  pulse  became  more  rapid.  The  abdomen  was 
opened  on  the  thinl  day.  There  was  no  evidence  of  inflammation.  The  pulse 
soon  rose  to  152,  and  the  temperature  was  101.6°  F.  on  the  following  day,  when 
she  died. 

Aut.  No.  52.  The  intestines  are  distended,  and  there  is  some  bloody  Huid  in 
the  abdomen.  Anatomic  diagnosis:  jjeritonitis,  general  anemia,  fatty  degenera- 
tion of  the  heart  and  kidneys.  Cultures  from  the  abdominal  wound,  from  the 
])elvis,  and  from  the  bloody  fluid  in  the  alxlominal  cavity  gave  a  growth  of 
Staphylococcus  ])yogenes  aureus. 

It  will  be  noted  that  when  the  abdomen  was  o{)ened  on  the  third  da}'  there 
was  no  evidence  of  inflammation.  When  the  drain  is  placed  in  the  abdomen, 
cultures  later  on  usually  yield  one  of  the  jnis-organisms.  In  this  case  it  looks 
as  if  death  was  due  to  obstruction  rather  than  to  peritonitis. 

S.  (Toronto),  June,  1903. 

Probable    General    Peritonitis.      Death. 

Mrs.  S.  was  seen  in  consultation  in  Toronto  June  8,  1903.  She  gave  a  history 
of  bleeding  for  a  short  time.  On  examination  the  uterus  was  found  to  be  the 
size  of  that  of  a  four  and  one-half  months'  ))regnancy,  but  freely  movable.  On 
section  of  the  alxlomen  the  growth  was  found  situated  in  the  anterior  wall.  On 
cutting  through  a  thin  layer  of  muscle  we  encountered  a  partially  degenerated 
myoma,  fully  12  cm.  in  diameter.  This  was  readily  shelled  out.  The  cavity  was 
obliterated  with  catgut,  and  a  few  silk  sutures  were  used  as  the  catgut  gave  out. 
The  patient  stood  the  operation  well,  but  died  three  days  later.  The  pulse  from 
the  time  of  o))erati()n  was  never  lower  than  135,  and  shortly  before  her  death 
reached  1()5.  The  tem])erature  varied  from  101°  to  104°  F.  She  had  no  vomit- 
ing or  distention,  and  the  bowels  moved  freely.  It  is  impossible  to  state  the  exact 
cause  of  death,  as  no  autoji.sy  was  allowed.  The  diagnosis  lay  between  peritoni- 
tis or  the  unaccountal)le  al)sori)tion  that  takes  place  even  when  no  infection 
occurs. 

Gyn.  No.  482. 

Abdominal  Myomectomy.  Death  f  i' o  in  Suppura- 
tive   P  e  r  i  t  o  n  i  t  i  s  . 

A.  W.,  single,  aged  twenty-three,  colored.  Admitted  December  20,  1S90; 
die(l  .lamiary  7,  1891.  Operation,  December  22d.  The  ovaries  on  both  sides 
contained  Graafian-foUicle  cysts.  The  tubes  and  ovaries  were  released  from 
adhesions  and  removed.  A  small  myoma  in  the  ]iosterior  wall  of  the  fundus 
was  transfixed  beneath  its  base  and  removed. 


ADBOMIXAL  MYOMECTOMY.  535 

Subsequent  History. — On  the  fifth  chiy  the  temperature  rose  to  ]()1.S°  V., 
and  examination  revealed  a  tender,  semifiuctuant  spot  in  the  left  l)r()ad  lijiament. 
On  the  sixth  day  the  temperature  reached  103.2°  F.,  the  pulse  IGO,  and  the 
patient  had  an  attack  of  vomiting.  The  abdomen  was  not  especially  sensitive 
and  not  distended.  The  incision  was  thoroughly  cleansed  with  l)ichloride,  and 
the  lower  portion  opened.  On  the  introduction  of  the  index-finger  a  small 
amount  of  blood  escaped.  The  omentum  and  intestines  were  adherent  to  the 
myomectomy  wound  in  the  uterus,  and  also  at  the  i)oints  from  which  the  tubes 
and  ovaries  had  been  removed.  These  adhesions  were  separated,  and  about 
30  c.c.  of  ])lood  escaped.     A  drainage-tube  was  inserted  behind  the  uterus. 

The  patient  seemed  to  improve  slightly  at  first,  but  later  became  gradually 
weaker.  The  abdomen  became  more  tympanitic  and  the  pulse  became  moic 
rapid  and  poor  in  vohime.  She  complained  of  severe  thirst,  had  several  in\(>l- 
untary  stools,  and  died  in  a  semiconscious  state  on  the  twelfth  day.  The  tem- 
perature ranged  between  99°  and  102°  F.     The  pulse  just  prior  to  death  was  156. 

Cultures  after  the  second  operation  showed  Staphylococcus  aureus.  In  this 
case  the  trouble  was  undoubtedly  primarily  an  obstruction  due  to  adhesions,  and 
following  the  second  ojieration  peritonitis  developed. 

Gyn.  1862. 

Abdominal  Myomectomy;  Intestinal  0  1)  s  t  ruction 
Followed    by    Peritonitis.      Death. 

L.  J.,  single,  aged  thirty-eight,  colored.  Admitted  March  15;  died  A))ril 
10,  1893.  Operation,  March  22d.  A  sessile  tumor,  10  x  12  cm.,  was  enucleated 
from  the  anterior  surface  of  the  fundus,  and  a  smaller  myoma,  2x3  cm.,  from 
the  posterior  surface. 

The  patient  subsecpiently  developed  some  tenderness  and  swelling,  with 
marked  constipation.  She  w^as  anesthetized,  and  a  hand,  introduced  into  the 
rectum,  broke  up  adhesions  by  which  some  of  the  loops  of  the  small  intestine 
had  become  adherent  to  the  pelvis.  Later  the  patient  Noniiteil  soiue  fecal 
matter,  and  a  s(M*ond  ()])ei-ation  was  ])erformed.  The  abdomen,  which  was  di.s- 
tinctly  distended,  was  opened,  and  the  intestines  wer(>  found  greatly  inliamed 
and  somewhat  adherent.  In  releasing  the  intestines  the  jx-i-itoneal  coat  was  torn 
in  several  places — in  one  j)lace  so  badlyas  to  necessitate  a  resection  of  the  l)o\vel. 
Some  fecal  matter  escaped.  A  drain  was  introduced  into  the  |)elvis  and  to  the 
j)oint  of  the  intestinal  resection. 

The  tem))eratui"e  after  the  first  operation  was  behiw  100"  !•".,  niid  iliij  not  go 
much  higher  until  the  (ifteeiith  day,  the  day  after  llie  second  operation.  It 
then  rose  to  102.2°  F..  and  the  pulse  to  150.  The  patient  died  of  ]terilonitis  on 
the  twentieth  day. 

With  oiu'  ])resent  knowledge  of  intestinal  ol)sl  i-uci  ion  we  would  not  lliink  of 
loosening  up  adhesions  thi'ough  llie  rectum  without  knowing  the  exact  condition 
in   the  pelvis.      Adhesions    are  now    ne\-ei-    liUeraled    except    luidei'  sight.     The 


536  MYO.MATA    OF   THE    UTERUS. 

primary  cause  of  death  in  this  case  was  un(loul:)te(lly  the  adhesions,  which  pro- 
duced intestinal  obstruction.     Such  a  case  would  now  call  for  an  enterostomy. 

Gyn.  No.  5638. 

Intestinal  ( )  1  >  s  t  r  u  c  t  i  o  n  Following  A  b  d  o  m  i  n  a  1  M  y  - 
o  m  e  c  t  o  m  y  .      J)  v  a  t  h  . 

M.  K.,  single,  aged  thirty-seven,  white.  Admitted  October  26;  died  Nov- 
ember 4,  1897.  Oi)eration,  myomectomy  and  suspension.  A  large  myoma 
was  enucleated  from  the  posterior  wall  of  the  uterus,  and  five  smaller  nodules 
from  the  anterior  surface. 

After  operation  all  attempts  to  move  the  bowels  were  fruitless.  The  patient 
vomitetl  continually,  the  vomitus  later  having  a  fecal  odor.  The  temperature 
varied  between  98.4°  and  100°  F.  The  pulse  became  gradually  more  rapid  and 
weaker,  reaching  132  on  November  3d. 

Second  operation:  release  of  adhesions;  release  of  suspended  uterus.  The 
intestines  were  distended  with  gas.  Adhesions  of  omentum  and  small  intestines 
to  the  utcM'us  obstructed  a  looj)  of  small  IxjwcI.     A  gauze  drain  was  introduced. 

The  temperature  rose  to  103°P\,  the  pulse  reached  144,  and  was  very  thready 
in  character.  There  was  much  nausea  and  vomiting,  and  the  patient  died 
about  twenty-four  hours  after  the  second  operation. 

Gyn.  No.  7560. 

A  1)  d  o  ni  i  n  a  1  M  y  o  m  e  c  t  o  ni  y.  Streptococcus  Peritoni- 
tis.     Death. 

J.  B.  C,  aged  forty-four,  white.  Admitted  February  7;  died  February  15, 
1900.  Operation,  February  12th,  abdominal  myomectomy:  suspension  of  the 
uterus.  A  myoma,  al)out  4.5  cm.  in  diameter,  was  removed  from  beneath  the 
left  round  ligament.  The  tubes  and  ovaries  were  normal.  At  the  time  it  was 
noted  that  the  colon  was  much  distended  with  gas. 

In  the  peritoneum  over  the  bladder  there  aj)peared  a  slightly  elevated  area, 
1x2  cm.  This  .^eemed  to  be  a  thickening  of  the  bladder-wall,  which  did  not, 
however,  a])pear  inflamed.  After  the  operation  the  patient  suffered  from 
nausea  and  vomiting.  The  vomitus  was  dark  brown  in  color,  and  suggested  an 
admixture  of  clotted  blootl.  Her  first  night  was  fairly  comfortable.  She  voided 
a  small  quantity  of  urine.  The  pulse  ranged  between  80  and  104,  the  tempera- 
ture between  98°  and  100.5°  F.  The  nausea  grew  worse.  At  the  end  of  twenty- 
four  hours  the  tongue  was  very  dry  and  the  abdomen  was  distended,  but  at  first 
there  was  no  tenderness.  The  bowels  did  not  move  until  several  enemata  had 
been  given.  On  the  third  day  the  tempeiature  reached  104.8°  F.  A  diagnosis 
of  general  peritonitis  was  made. 

Operation,  February  14th.  At  the  u))))er  angle  of  the  wound  some  creamy 
white  pus  was  noted  along  the  sutures.  The  incision  was  opened,  the  peritoneal 
sutures  were  cut,  and  a   seropurul(>nt    fluid,   slightly  l-)lood-tinged,  welled  up. 


ABDOMINAL  MYOMECTOMY.  537 

Cover-slips  from  this  showed  streptococci.  The  intestines  were  injected  and 
covered  with  a  fibrinous  deposit.  The  omentum  was  injected.  There  were  no 
adhesions.  The  alxlominal  cavity  was  Hushed  out.  The  patient  (Ued  the  fol- 
lowing day. 

Gyn.  No,  1035 1. 

Abdominal  ^I  y  0  m  e  c  t  o  m  y  F  o  11  0  w  e  d  by  Intestinal 
Obstruction.      Death. 

L.  B.  D.,  aged  thirt^'-five,  colored,  married.  Admitted  March  24;  died 
March  29,  1903.  At  operation  a  multinodular  myomatous  uterus  was  found 
filling  the  pelvis,  and  extending  to  within  5  cm.  of  the  umbilicus.  The  uterine 
vessels  were  controlled  by  a  rubber  tube  drawn  around  the  cer\-ix.  The  uterus 
was  then  bisected,  and  28  myomata  of  various  sizes  were  shelled  out.  The  cervix 
was  dilated,  an  iodoform  pack  put  in  the  uterine  canal,  and  the  uterus  .sewn  up 
with  two  layers  of  catgut  sutures.  The  bleeding  was  ap])arently  successfully 
controlled.  There  was,  however,  slight  oozing,  and  several  stri})s  of  iodoform 
gauze  were  left  in  the  lower  end  of  the  abdominal  incision.  The  patient  left  the 
table  in  excellent  condition. 

Four  hours  after  operation  the  tem])erature  reached  101°  F.,  the  i)ulse  was 
100.  Twenty-four  hours  later  the  ])ulse  was  130.  The  temperature  never  was 
higher  than  101°  F.  Her  pulse  became  gradually  higher  until  the  fifth  day  at 
9  A.  M.,  when  she  died.  Eight  hours  after  the  operation  the  l)in(ler  was  stained 
through  with  l)lood.  Her  bowels  refused  to  move  and  she  had  (juite  marked 
abdominal  distention,  which  began  twenty-four  hours  after  the  operation.  The 
restlessness  increased  shortly  after  the  operation. 

On  the  fourth  day  she  was  removed  to  the  operating  room,  and  under  gas  an 
enterostomy  was  done.  When  the  abdominal  cavity  was()])ened,  a  large  amount 
of  tarry  blood  escaped,  together  with  some  clots.  The  intestines  were  modi'rately 
distended.  A  loop  of  small  intestine  was  brought  out  and  opened.  There  was 
an  escape  of  gas,  but  no  fecal  matter.  After  this  second  operation  there  was  no 
imjirovement ,  and  the  ])a(ient  gradually  grew  weakei'  and  died.  She  liail  what 
ajijK'ared  to  be  fecal  vomiting  before  death. 

The  myomata  varied  from  1  to  1.5  cm.  in  diameter. 

In  this  case  it  would  have  been  iinieh  wiser  to  have  done  a  hysterectomy  in- 
stead of  a  myomectomy,  especially  when  so  iiiany  myomata  were  i)resent.  After 
splitting  almost  entii'cly  thi'ough  the  uterus  it  is  exceedingly  diflicult  to  apjiroxi- 
mate  the  two  halves,  and  at  the  same  time  absolutely  to  check  bleeding. 

Possible  Cerebral  Embolus  with  Hyperpyrexia. 

In  Case  105SS,  in  which  a  nniltiple  niyoinectomy  was  done,  the  pulse  soon 

rose  to  140,  and  gradually  became   ]tooi-ei'  in   (|uality.     The  abdomen  showed 

slight  distention,  and   the   patient  became  drowsy.      Ilei-   lem|)ei-alui-e  suddenly 

rose  to  107°  F.  shortly  befoi'e  her  death  on  the  third  dav.     41ie  abdominal  inci- 


538  MYo.MATA    OF   THK    UTKRl'S. 

sioii  was  opened  after  death.  Not  over  an  ounce  of  blood-stained  fluid  was 
found.  There  were  no  e\idenees  of  ])eritonit is.  and  euH ures  were  negative.  In 
this  ease  the  symptoms  suggesteil  a  cerelji'al  embolus. 

Gyn.  No.  10588. 

M  u  1  t  i  p  1  e  A  b  d  o  m  i  n  a  1  M  y  o  m  e  c  t  o  ni  y  .  D  e  a  t  h  w  i  t  h 
Indefinite   Signs. 

I>.  II..  single,  aged  forty,  white.  Admitted  .hily  o:  died  .luly  S,  1903.  The 
patient  was  well  noui'ished  and  had  a  good  color.  The  heart  and  lungs  were 
apparentlv  nonnal.  The  utei'us  contained  .•<evei-al  myomata.  varying  from  0.5 
to  5  cm.  in  diameter. 

The  operation  was  ])erfectly  sim])le,  and  the  patient  was  returned  to  the  ward 
in  good  condition.  Soon  after  her  pulse  rose  to  140,  but  remained  of  good 
volume  for  twenty-four  hours.  Th(>  second  night  she  was  quite  uncomfortable. 
She  was  given  calomel  on  the  second  day,  followed  by  Epsom  salts  and  enemata, 
wliicli  were  not  effectual.  On  the  third  day  her  ])ulse  was  120;  her  tem])erature, 
100°  F.  She  was  comfortable,  and  slept  well  during  the  night.  About  11  a.  m. 
there  was  a  sudden  collapse.  Tn  the  afternoon  her  tem])erature  rose  to  107°  F. 
There  was  no  pallor  and  no  symptoms  except  the  tem])erature  were  present  to 
indicate  ])erit()nitis.  l^]verything  pointed  strongly  to  ;ui  end)olus  involving  a 
thermic  centei-.  She  gradually  grew  weaker,  and  died  at  7  p.  M.  We  had  per- 
mission to  open  the  abdominal  incision  and  found  the  intestines  perfectly  smooth. 
There  was  not  an  ounce  of  blood  in  the  alxlomen.  The  stitches  had  held  every- 
where in  the  uterine  wall,  and  on  o])ening  the  uterus  we  found  that  none  had 
entered  the  uterine  cavity.  Furthermore,  there  were  no  dead  spaces  containing 
blood. 

This  is  one  of  those  cases  in  which  the  patient  dies  and  yet  no  definite  assign- 
able cause  can  be  detected  without  the  most  thorough  autopsy.  The  probability, 
however,  is  that  .she  had  an  embolus.  Cultures  from  the  peritoneal  cavity  were 
negative. 

.\  few  years  later  we  learned  that  this  patient  shortly  before  entering  the 
hospital  had  told  several  fi'iends  that  she  w\as  sure  she  was  going  to  die.  In  all 
cases  in  which  the  patient  has  a  |)ersistent  premonition  of  death,  ojieration,  if 
not  immediatel\'  imperative,  should  be  deferred  until  the  chances  of  success 
have  been  so  thoi'oughly  impressed  ui:)on  th(^  patient  that  her  mental  attitude 
is  changed  and  she  promisees  to  do  all  she  can  toward  getting  well. 

In  this  case,  as  is  said  elsewhei'e.  we  wished  to  do  a  hysterectomy,  but  were 
ham])ere(l  by  our  jiromise  to  the  patient  to  sa\'e  the  uteinis. 


Fatal  Myomectomy  During  Pregnancy. 
The  patient  had  been  mai'i'ied  eleven  years  and  had  never  been  ])regnant 
before.     At   operation    a    four    months"    pregnancy   was   detected.     Numerous 


ABDOMINAL    MYOMECTOMY.  539 

nodules  stiulded  the  uterus.  A  myoma  7  cm.  in  diameter  was  removed  and 
some  difficulty  was  experienced  in  controlling  the  bleeding. 

Intestinal  atony  developed,  undoubtedly  favored  by  the  pregnancy.  Mis- 
carriage followed,  and  the  patient  soon  died.  Infection  certainly  played  a  very 
minor  role  in  this  case. 

For  the  successful  abdominal  myomectomies  during  ])regnanc5^  see  p.  52.S. 

With  our  present  knowledge  we  would  not  think  of  doing  a  myomectomy  in 
such  a  case.  The  abdomen  would  be  closed  at  once,  the  pregnancy  being  al- 
lowed to  go  on  to  term,  after  which,  if  necessary,  hysterectomy  or  myomectomy 
would  be  performed. 

Gyn.  II 1 10. 

A  b  d  o  m  i  n  a  1  M  y  o  m  e  c  t  o  m  y  D  u  ring  P  r  e  g  n  a  n  c  y  .     1)  e  a  t  h  . 

C.  S.,  aged  thirty-three,  colored.  Admitted  March  9;  died  March  20.  1904. 
This  patient  had  been  married  ek^ven  years  and  had  never  been  pregnant.  Opera- 
tion, March  14,  1904.  When  the  abdominal  cavity  was  opened,  a  large,  soft, 
pregnant  uterus  was  found.  The  pregnancy  had  probably  run  about  four 
months.  Many  small  nodules  were  scattered  over  the  surface  of  the  uterus, 
and  one  of  the  larger  tumors,  about  7  cm.  in  diameter,  was  removed.  Ther(>  was 
some  difficulty  in  controlling  the  bleeding. 

Postoperative  History. — After  the  operation  morphin  was  given  rather 
freely  during  the  first  forty-eight  hours,  to  prevent,  if  possible,  miscarriage.  On 
the  evening  of  the  second  day  the  temperature  was  101.6°  F.,  and  at  noon  of  the 
next  day  it  was  again  normal.  Cathartics  were  given  on  the  second  day,  but 
neither  these  nor  enemata  had  any  effect,  and  the  intestinal  distention  increased 
rapidly.  On  the  night  of  the  third  day  she  was  quite  ill:  her  pulse  was  118,  and 
the  al)domen  considerably  distended.  Leukocytes,  3(3,000.  The  distention 
became  somewhat  less,  and  her  leukocytes  dropped  to  11,000.  The  bowels  did 
not  move,  however.  There  were  no  signs  of  bleeding  from  the  vagina  until  the 
night  of  the  fifth  day,  when  she  suddenly  passed  a  small  fetus.  The  placenta 
had  to  be  I'emoved  manually. 

The  distention  was  becoming  greater,  the  pulse  had  become  moi-e  rapid,  and 
on  the  sixth  day  an  enterostomy  was  done  under  cocain.  Her  jnilse  at  this  time 
was  130  and  weak.  The  incision  was  made  through  the  outer  l)()rder  of  the  right 
rectus  nuiscle  and  the  ])eritoiieal  cavity  openetl.  Thei-e  was  much  free  blood: 
the  intestinal  coils  wei'e  much  distended,  but  otherwise  noi'iiial.  A  loop  ol  large 
bowel  was  brought  int(j  the  wound  and  sulured  with  catgut. 

Cultui'es  taken  from  the  bloody  fluid  al  the  lime  of  the  second  ojiei-ation 
yielded  St  aphylo('oC(ais  albus.  The  temperat  ui'e  steadily  I'ose  to  10."!. T)"  !■..  and 
she  died  on  \\\o  followiiiir  afternoon. 


540  MVO.MATA    OF   THE    LTERUS. 

Probable  Infection  of  the  Uterus  from  an  Undetected  Carcinoma  of  the  Body 

OF  THE  Uterus. 

In  looking  over  the  history  of  Case  1173  it  will  be  noted  that  the  patient  had 
a  slimy,  watery,  vaginal  discharge.  This  is  very  significant  in  connection  with 
the  subsequent  history,  but  at  the  time  was  cncrlooked.  In  this  case  the  uterus 
was  bound  down  by  adhesions  and  contained  two  myomata.  One  of  these, 
about  7  cm.  in  diameter,  was  enucleated.  The  other  could  not  be  shelled 
out  on  account  of  adhe.-^ions.  The  patient  died  on  the  sixth  day  of  acute  purulent 
peritonitis. 

This  operation  was  performed  in  1892,  when  the  technic  of  myomectomy  had 
not  been  fully  developed.  Now  we  would  not  think  of  tr3'ingto  save  the  uterus 
in  such  a  case,  but  would  perform  hysteromyomectomy.  The  finding  of  a 
carcinoma  of  the  body  of  the  uterus  at  autopsy  gives  us  a  very  valuable  surgical 
hint.  In  all  cases  in  which  we  advise  abdominal  myomectomy,  as  far  as  possil:)le 
we  exclude  the  presence  of  a  carcinoma  of  the  body.  In  the  chapter  on  Carcinoma 
of  the  Body  and  Myoma,  it  was  clearly  demonstrated  tliat  in  numerous  cases 
carcinoma  was  not  suspected  until  the  uterus  was  opened  up  after  its  removal. 

^lyomectomy  in  the  presence  of  an  adenocarcinoma  of  the  body  is  naturally 
almost  certain  to  give  rise  to  infection. 

Gyn.  No.  1173.     Aut.  277. 

A  b  (1  o  111  i  n  a  1  M  y  o  111  e  c  t  o  in  y  C  o  m  plicated  1)  y  an  U  n  - 
s  u  s  p  e  c  t  (■  d  A  (1  ('  II  o  c  a  r  <•  i  n  o  ni  a  o  f  t  h  e  B  o  d  }•  o  f  t  h  e  U  t  e  r  u  s  . 

A.  B.,  single,  aged  forty-three,  colored.  Admitted  January  2(i;  died  Feb- 
ruary IS.  1802.  In  Xovenil)er.  1801.  two  small  myomata  were  removed  per 
vaginam  in  New  York.  Three  and  a  half  months  ago  the  i)atient  noticed  a  lump 
in  the  left  iliac  regicjii.  She  has  a  slimy,  watery,  vaginal  discharge,  with  occa- 
sional clots,  is  very  anemic,  and  has  a  double  apical  heart  murniur. 

Operation,  February  13,  1892.  The  uterus  was  distended  by  two  myomatous 
masses;  the  anterior,  about  7  cm.  in  diameter,  was  removed.  The  ])osterior, 
which  was  slightly  larger,  was  bound  down  by  adhesions,  which  prccliuh'd  its 
enucleation. 

The  i)atieiil  Nonntcd  many  times  after  operation.  The  abdomen  l)ecaine 
distended,  the  pulse  rai)id,  and  the  tein])erature  rose  to  103°  F.  on  the  fifth 
day,  dropping  to  101.5°  F.  on  the  sixth  day.  the  day  of  her  death.  That  day 
the  patient  was  covered  with  a  cold,  clammy  sweat  and  voided  urine  involuntarily. 

Aut.  No.  277.  Anatomic  diagnosis:  Acute  j)uriileiit  peritonitis.  Myoma 
and  carcinoma  of  the  uterus;  general  arteriosclerosis;  cardiac  hy))ertrophy; 
chronic  difl'use  nei)hritis;  broncho])neuinonia  (right  lung).  The  peritoneal 
c;)\ify  showed  \nu-c  Stai)hylococcus  pyogenes  aureus. 


ABDOMINAL  MYOMECTOMY.  541 

A  Death  Probably  from  Faulty  Catgut. 

Bet^veen  January  IS  and  25,  1S93,  five  laparotoniies  were  performed  in  the 
Gynecological  Department  of  the  Johns  Hopkins  Hospital  and  four  of  these 
patients  died.*  In  all  the  fatal  cases  the  operation  \vas  a  simple  one,  and  the 
abdomen  at  the  time  of  operation  was  apparently  perfectly  clean.  In  the  fifth 
ease — one  of  pyosalpinx — the  patient  recovered. 

In  all  the  cases  Staphylococcus  aureus  was  found.  The  source  of  infection 
appeared  to  be  some  old  catgut,  but  it  was  impossible  to  determine  with  certainty, 
as  all  the  catgut  had  been  used,  none  remaining  for  bacteriologic  examination. 

This  case  was  one  of  the  four  fatal  cases. 

Gyn.  No.  1752. 

Abdominal  Myomectomy;  General  Peritonitis  Ap- 
parently   Due    to    Fault}"    Catgut.     D  e  a  t  li  . 

E.  H.,  aged  thirty-four,  white.  Admitted  January  12;  died  January  20, 
1893.  Operation,  January  23,  1893.  Two  symmetric  myomata  were  discovered, 
one  in  the  anterior  wall,  8.5  cm.,  and  one  in  the  jxjsterior  wall.  8  cm.  in  diameter. 
Both  of  these  were  enucleated,  as  were  also  four  other  smaller  ones. 

On  the  night  of  the  second  day  the  patient  complained  of  severe  stabbing 
pain  over  the  area  of  the  lower  lobe  of  the  left  lung.  The  pain  was  increased  on 
deep  inspiration.  The  tongue  was  moist  and  slightly  coated;  the  abdomen  was 
not  distended.  On  the  following  day  the  pulse  was  120.  Her  expression  was 
bad.  She  had  been  nauseated  at  intervals  during  the  entire  day.  The  abdo- 
men was  prominent,  distentled,  tympanitic,  and  sensitive.  On  opening  the 
lower  angle  of  the  wound  the  operator  was  unable  to  find  any  evidence  of  pus. 
The  temperature  was  104.4°  F.  On  January  26th  it  rose  to  107.8°  F.,  and  tleath 
quickly  followed.    The  patient  was  conscious  to  the  last. 

Autopsy.  Anatomic  diagnosis:  Purulent  hemorrhagic  peritonitis  following 
abdominal  myomectomy;  stitch-hole  al)scesses;  acute  s])lenic  tumor;  emliolic 
lung  abscess;  congestion  of  ihc  lungs;  infection  witli  Streptococcus  ])yogenes 
and  Staphylococcus  pyogenes  aureus.  (The  auto))sy  findings  are  given  in  full 
in  the  Johns  Plopkins  Hospital  Peports,  1895,  vol.  iv,  j).  412.) 


Probable  Infection  from  Fluid  Liberated  from  the  Fallopian  Tubes. 
In  Case  5124  the  uterus  not  only  contained  mnnerous  myomata,  but  was  also 
denselv  adherent.  \Mien  the  al)doinen  was  opened,  the  right  tube  and  a  myoma. 
4  cm.  in  diameter,  were  removed,  and  an  artilicial  linilnialeil  end  was  made  for 
the  left  tube.  After  many  ui)s  and  downs  this  patient  dieil  about  six  wi-eks 
after  ojjeration. 

*  Thoinus   S.  C'lilleii,  rostoperative   Septic   roritonitis,  'I'ho  ,I.>lins    lloiikins    Hosp.   Reports, 
voL  iv,  1S9.3,  p.  411. 


542  MVO.MATA    OF    THK    rTHRfS. 

In  Case  11296  a  myoma,  6  cm.  in  diameter,  was  shelled  out  of  the  posterior  wall, 
and  both  tubes,  which  were  filled  with  clear  fluid,  were  ])unctured.  the  fluid 
escaping  into  the  abdominal  cavity. 

The  surgical  ti-catnicnt  in  both  of  these  cases  is  o])en  to  criticism. 

In  (  ase  5124  we  (CuUen)  would  have  shown  nuich  better  judgment  had  we 
done  a  hysterectomy.  In  Case  ]129()  both  tubes  should  have  been  removed 
and  no  lluid  allowed  to  escajx'  into  the  abdominal  cavity.  The  occlusion  of  the 
tube  was  primarily  due  to  an  infection,  and  we  can  never  tell  when  all  the 
organisms  are  dead. 

Gyn.  No.  5124. 

A  b  d  o  in  i  n  a  1  M  y  o  in  e  c  t  o  111  y  ;  Release  of  Adhesions  ; 
t  h  e  .M  a  king  o  f  a  n  A  r  t  i  fi  c  i  a  1  I''  i  m  b  r  i  a  t  e  d  }■]  x  t  r  e  m  i  t  y 
f  o  r    On  e    T  u  be  .       1)  ea  t  h  . 

A.  M.  H.,  aged  forty,  married,  colored.  Admitted  .March  2.'5 ;  died  May  o. 
1807.  Ojjeration.  March  2()th.  vaginal  section  with  release  of  adhesions.  Second 
operation,  April  lOth.  Fehic  adhesions  were  liljerated  from  above,  the  right 
tube  was  remo\'ed.  a  niN'oma  4  cm.  in  diameter  enucleated  from  the  uterine  wall, 
and  an  artificial  oix'iiing  made  in  the  left  tube.  Other  myomata  were  seen,  but 
were  not  disturbed. 

The  abdominal  inci.sion  broke  down  for  its  entire  length,  necessitating  di-ainage. 
SuV)se(|ueiUly  on  two  occasions  i)eh-ic  drainage  was  reestablished  from  below. 
The  ))atient.  however,  gradually  grew  weak(M'.  the  pulse  more  raj)id,  and  she  died 
on  May  o,  1X97. 

In  this  case  the  fact  that  the  abdominal  incision  hrokedown  notwithstanding 
the  careful  technic,  indicates  a  very  low  vitality.  At  the  time  of  oj^eration  it 
would  ha\'e  been  much  wiser  to  remove  the  ut(M'us  with  the  appendages,  instead 
of  trying  to  do  a  conservative  oj:)eration. 

Path.  No.  !()().").  Th(>  right  tulx"  is  S  cm.  in  length,  firmly  covered  by  dense 
adhesions.     It  contains  a  yellowish,  cheesy-like  material. 

Histologic  examination  shows  the  tube  to  be  the  seat  of  a  chronic  .salpingitis. 

Gyn.  No.    11296. 

A  1)  d  o  in  i  n  a  1  .M  y  o  in  e  c  t  o  in  y  ,  1']  v  a  c  u  a  t  i  o  n  o  f  S  e  r  o  u  s 
F  1  u  i  d     f  r  o  m     B  o  t  h     V  a  1  1  o  p  i  a  n     Tubes.      1)  e  a  t  h  . 

\'.  S.,  aged  thirty-four,  white,  mai-ried.  Admitted  May  19th;  died  May  28, 
1904.  The  patient  was  intensely  neurotic  and  rather  anemic.  She  was  fairly 
well  iiom-ished  and  well  built.  ()peratioii,  May  21,  1904.  A  myoma,  6  cm. 
in  diameter,  was  enucleated  fi'om  the  posterior  wall.  Both  tubes  were  the  seat 
of  a  hydro.salpinx.  They  were  punctured,  fluid  escaping  into  the  abdominal 
cavity. 


ABDO.MIXAL    .MV(XMi:CT(J.M Y.  543 

Postoperative  History. — For  four  days  she  diel  fairly  well.  Her  temperature 
was  101.2°  F.  on  the  second  day;  the  third  day  it  reached  100°  F.;  the  fourth 
day  it  was  down  to  99°  F.,  but  she  began  to  vomit.  Enemata  had  no  effect.  On 
the  fifth  day  she  was  nauseated  nearly  all  day,  took  but  little  nourishment,  but  had 
no  abdominal  pain.  There  were  six  small  offensive  fluid  stools.  Her  tem- 
perature on  the  fifth  day  varied  from  99°  to  102°  F.  Her  pulse,  however,  at  one 
time  reached  130,  and  her  general  condition  was  not  satisfactory.  The  nausea 
continued.  The  wound  was  inspected  and  found  to  be  clean.  Lavage  relieved 
her  gastric  symptoms  a  good  deal. 

On  the  seventh  day  she  began  to  have  diarrhea,  and  the  same  afternoon  her 
condition  suddenly  became  worse:  she  grew  very  weak,  restless,  and  slightly 
irrational;  her  pulse  reached  140,  and  she  died  on  the  eighth  day.  Just  before 
her  death  the  cheeks  were  flushed,  the  eyes  were  bright,  and  the  intellect  was 
active;  there  was  no  pain  or  rigidity.  She  was  intensely  restless.  No  autopsy 
was  allowed,  but  we  diagnosed  a  general  peritonitis.  Shortly  before  death 
the  temperature  was  106.5°  F. 


The  Patient  in  an  Almost  Moribund  Condition  before  Operation. 
Many  an  ai)parently  forlorn  hope  yields  a  brilliant  surgical  triumph,  and  as  long 
as  there  is  a  possiljility  of  saving  the  patient,  it  is  the  surgeon's  duty  to  take 
that  chance.  In  the  following  case  the  patient  was  in  a  desperate  condition  and 
succumbed  on  the  table.  The  death,  of  course,  cannot  be  in  any  way  attributed 
to  the  abdominal  myomectomy,  but  it  is,  nevertheless,  included  among  our  fatal 
cases. 

Gyn.  No.   1672. 

R  e  m  o  V  a  1  o  f  a  L  a  r  g  e  C  y  s  t  i  c  M  y  o  m  a  f  r  o  m  a  Patient  i  n 
a  n    A  1  m  o  s  t    Moribund   ('  o  n  d  i  t  i  o  n  .     1)  e  a  t  h    on    the   T  a  b  1  e  . 

P.,  .single,  white.  Admitted  November  12;  died  November  13,  1892. 
The  patient,  on  admission,  was  suffering  with  extreme  dyspnea  and  was  unable 
to  lie  down.  The  abdomen  was  much  distended,  fluctuant,  and  dull  on 
percussion  e\'erywhere,  except  at  the  center  of  the  upper  abdominal  zone.  The 
circmnference  at  the  umbilicus  was  52  inches.  The  urine  contained  a  motlerate 
amount   of  albiiiiiiii,  but   110  casts. 

Operation  November  13th.  The  anesthetic  was  administered  with  the  patient 
in  the  sitting  ])ostui"e,  on  account  of  the  extreme  dys])nea. 

A  small  incision  was  made  near  the  (lepeiideiu  portion  of  the  abdomen, 
a  trocai-  was  inserted,  and  from  four  to  six  pints  of  fluid  deeply  stained  with  blood 
came  away.  The  almost  moribund  j)atient  was  then  placed  on  the  operating 
table.  The  incision  was  increased  in  length,  and  a  iai'ge  (juantity  of  blood- 
stained fluid  flowed  out.  The  iai'ge  flbrocyslic  tumoi"  was  shelled  out  of  its  ad- 
hesions, which  wei'e  flbrous  and  oiiienlal  in  chai'actei".  The  pulse  and  i-es))iration 
stopped.     The  patient  was  in\-ei1e(l,  and  artificial  I'espirat ion  resorted  to,  but  to 


544  MYOMATA  OF  THE  ITERUS. 

no  i)urposc.  The  pulse  before  opemtion  was  160.  The  tumor  was  a  cystic 
myoma,  30  x  34  cm.,  the  inner  portion  hcins:;  composed  of  one  large  cyst  filled  with 
chocolate-colored  contents.  The  base  of  the  tumor  measured  14x16  cm.  and 
was  composed  of  typical  iiiN'omatous  tissue. 

Myocarditis  as  a  Possible  Cause  of  Death  Following  Abdominal  Myomectomy. 
In  (".  II.  I.  ease  W'.,  the  patient  gave  a  history  of  cardiac  weakness,  and  at  the 
end  of  twenty-four  hours  after  operation  became  weak  and  had  fainting  spells. 
None  of  her  symptoms  except  vomiting  in  any  way  suggested  peritonitis.  Un- 
fortunately, no  autopsy  could  hv  obtained.  Her  postoperative  condition  strongly 
suijtrested  a  mvocardial  lesion. 


'&o^ 


C.  H.  I.,  W. 

W'..  white,  aged  thirty-eight  years,  was  admitted  to  the  Church  Home  and  In- 
firmary ( )ct()l)er  lOth,  and  died  October  12, 1899.  She  had  noticed  an  abdominal 
eniai'geiiient  about  a  year  before.  The  tumoi'  had  grown  considerably  since  she 
was  examined,  six  months  before.  A  myoma,  16  cm.  in  diameter,  was  removed 
from  the  ))()sterior  wall,  and  several  small  ones  from  both  the  anterior  and  poste- 
rior walls.  The  patient  was  weak,  but  did  fairly  well  for  twenty-four  hours. 
She  had  fainting  spells  on  the  afternoon  of  October  12th,  vomited  a  good  deal, 
and  died  suddenly  the  .same  evening.  There  was  no  abdominal  distention,  no 
hemorrhage.  Her  temperatui'e  had  been  normal  throughout.  No  autopsy 
was  obtainal)le. 

Dr.  W.  V.  Hines,  of  Chesterto\Mi,  ^Id.,  her  family  physician,  informed  me 
t  hat  on  several  occasions  .she  had  suddenly  collapsed,  and  that  he  thought  she  had 
a  myocardial  infection.  W'v  are  unable  to  say  with  absolute  certainty  whether 
or  not  such  was  the  condition. 


Immediate  Postoperative  Complications  in  Non-fatal  Cases  of  Abdominal 

Myomectomy. 

By  immediate  we  mean  those  occurring  during  the  patient's  sojourn  in 
the  hospital.  <')f  the  280  i)atients,  ([uite  a  mimber  had  mild  or  serious  com})li- 
cations.  These  are  of  suthcient  practical  importance  to  warrant  a  thorough 
consideration. 

The  postoperative  complications  encountered  were: 

High  temperature. 

Ka])id  ])ulse. 

Ilystei'ieal  manifestations. 

Excessive  nausea  and  vomiting. 

Postoperative  hemorrhage. 

Great  abdominal  pain. 

Cystitis. 


ABDOMINAL   MYOMECTOMY.  5-45 

Nephritis. 

Escape  of  pus  from  the  urethra. 

A  foul  uterine  discharge. 

Sloughing  of  the  anterior  uterine  wall. 

Pelvic  peritonitis. 

Intestinal  obstruction. 

A  high  leukocytosis. 

Abscess  in  the  broad  ligament,  with  spontaneous  evacuation  into  the  bladder. 

Tonsilhtis. 

Bronchitis. 

Pleurisy. 

Bronchopneumonia. 

Lobar  pneumonia. 

Phlebitis. 

B(Hlsore. 

Temperature  and  Pulse  after  Abdominal  Myomectomy. — Elevation  of  tem])cr- 
ature  Avith  an  acceleration  of  the  pulse  is  a  connnon  occurrence  after  an  al)dominal 
myomectomy,  and  causes  the  surgeon  much  anxiety.  As  a  rule,  both  temperature 
and  pulse  drop  gradually,  reaching  normal  several  days  after  operation.  Of  the 
cause  of  the  increased  temperature  we  know  little  or  nothing.  On  reopening  the 
abdomen  in  some  of  the  severer  cases  we  have  found  no  hemorrhage  nor  infection. 
It  is  quite  possible  that  in  many  cases,  notwithstanding  the  surgeon's  care, 
there  exist  small  accumulations  of  blood  in  spaces  that  have  not  been  totally 
obliterated,  and  that  the  disintegration  and  absorption  of  this  l)lood  may  in  some 
way  be  responsible  for  the  increased  temperature.  No  other  class  of  abdominal 
operations  has  given  us  as  much  anxiety  during  the  first  week  following  operative 
interference. 

In  242  of  the  cases  we  have  com})lete  data  as  to  the  postoperative  temperature 
and  juilse. 

That  the  findings  ma}'  be  ])resented  as  concisely  as  possible,  tables  haA'e  been 
pi'epared.  In  these  are  included  the  postoperative  tein])erature  and  pulse-rate 
during  the  first  week,  as  abnormalities  after  this  period,  with  a  few  exceptions, 
were  associated  with  posto]X'rative  complications  and  are  considered  in  the  discus- 
sion of  that  su])ject.  Only  the  highest  teni])erature  and  pulse-rate  are  considered, 
and  the  grouping  of  the  cases  is  arranged  accordingly,  as  seen  in  TaJjles  1  and  111. 
In  Table  II  ai'e  included  cases  showing  a  tenn)erature  abovi'  102°  F..  the 
striking  feature  being  the  absence  of  any  clear  cause  for  such  iis(>.  Similarly, 
in  Table  R'cases  showing  a  high  pulse-rate  are  considered,  and  hei-e  too.  in  the 
majority,  no  satisfactory  cause  can  be  assigned.  In  1 1  eases  the  pulse-rate  re- 
maine(l  high  during  the  greater  part  of  convalescence. 

Temperature. — From  a  consideration  of  Table!  it  will  i)e  seen  that   in  7S  per 
cent,  of  the  cases  the  inaxinmni  postopei'at  i\'e  tenipei'al  ure  during  the  lii'st  week 
was  over  100°  F. 
35 


546 


:myo.m.\ta  of  the  uterus. 


TABLE  I. 
Maximum  Postoper.vtive  Temperature  During  First  Week. 

98.8°, 1  case  (  0.4  per  cent.) 

99°— 100°,                                53  cases  (21.7  per  cent.) 

100°— 101°,                              127  cases  (52.9  percent.) 

101°— 102°,                                43       "  (17.9  per  cent.) 

102°— 103°,                               10       "  (  4.2  per  cent.) 

103°— 104.5°                               8       "  (  2.9  per  cent.) 
Total,                                242  cases 

Til  17  cases  the  tctiiperaturc  was  al)ovo  102°  F.     These  cases  are  shown  in 

1'al)l('  II.      ill  only  4  out  of  the  17  cases  could  any  definite  cause  l)e  assigned  for 

tills    elevation. 

TABLE  II. 
C-4SE.S   Showing    a    Maximal   Postoperative   Temperature   of    Over    102°    F.    in   the 

First  Week. 


Gyn.  No. 


Temperature. 


Day  after  Operation. 


.\ppARENT  Cause. 


121 

362 

6724 
9304 
1489 
8844 


102.2° 
103.4° 

102.4° 
l(r2.4° 
102  .-)° 
102.6° 


Seventh. 
Seventh. 

Second. 
Fourth. 
Tliird. 
Sixtli. 


7220 

102.8° 

Sixth. 

8476 

102.8° 

Second. 

4055 

103.0° 

Sixth. 

0059 

103.0° 

Second. 

0394 

103.0° 

Tliird. 

5452 

103.2° 

Filth. 

4929 

103.4° 

Sixth. 

858 

103.8° 

Filtii. 

2039 

104.2° 

Fourth. 

5359 

104.5° 

Fourth. 

Not  clear. 
Lung   involvement    (no    definite    consoli- 
dation). 

Lung  involvement. 


Tenderness  and  muscle  spasm  in  right 
iliac  fossa  following  appendectomy  and 
myomectomy. 

Not  clear. 


IIO.VJ 

Pulse. 

nieetoniy 

niaxiniun 


104..-)° 


S(M'()iid. 


Too     early     discontinuance 

di'ainage. 
Bronchopneumonia. 


of     vasrinal 


111  Ji; 

onU'  .")  of 


That  the  piilse-i'ate  is  inaterially  increased  after  abdominal  myo- 
is  evidenced  hy  the  fact  that  in  about  67  per  cent,  of  241  cases  the 
1  diirin.u'  llie  first  week  was  over  100,  as  is  shown  in  Talile  TIT. 

TABLE  III. 

Maximal  rosin i-kuative  Pulse-rate  Dnu.XG  the  First  Week. 

70—  80  1   case  (  0.4  per  cent.) 

80—  90  12  ca.ses  (  5.0  per  cent.) 

90—100  06       "  (27.5  percent.) 

100     110  69       "  (28.3  percent.) 

110      I -'(J  54       "  (22.5  percent.) 

120     130  23       "  (  9.75  per  cent.) 

130—140  11       "  (  4.57  per  cent.) 

Above  140  5       "  (  2.08  per  cent.) 

Total,  241   cases 

cases  the  niaxiiiiuin  i)ul^e-i'ate  durin<;'  the  (irst  week  was  over  loO.     Tn 
these  could  a  satisfactor\'  cause  he  assigned. 


ABDOMIXAL   MYOMECTOMY. 


547 


TABLE  IV. 
Cases  Showing  a  Ma.ximal  Postoperative  Pulse-rate  of  Above  130  During  First  Week. 


Gyn.  No. 

Pulse-rate. 

Day. 

.•\ppARENT  Cause. 

5588 

132 

Second. 

Not  clear. 

10059 

132 

Sixth. 

((       (( 

10587 

1.32 

Second. 

(<              u 

10394 

132 

Third. 

"       " 

11052 

132 

Second. 

Bronchopneumonia. 

2500 

136 

Third. 

Not  clear. 

8476 

136 

Second. 

"       " 

9221 

136 

Third. 

"       " 

858 

140 

Fifth. 

((       it 

6724 

140 

Second. 

a          i( 

8089 

140 

Fifth 

"          " 

12583 

144 

Third. 

Intestinal  obstruction;  beginning  post- 
operative peritonitis. 

1212 

148 

Third. 

Not  clear. 

10983 

160 

Second. 

Pulse  before  operation  160;  almost  im- 
perceptible after  operation.  Rapid  and 
irregular  during  convalescence. 

2772 

152 

Third. 

Not  clear. 

10300 

170 

First. 

Not  clear. 

Ill  11  case.s  the  pulse-rate  remained  high  (hiring  convalescence,  and  in  only 
2  of  these  (Gyn.  No.  10983  and  12583)  could  a  satisfactory  cause  be  assigned. 

In  Gyn.  No.  3980,  5588,  6585  and  7073  the  pulse-rate  was  above  100  for  several 
days. 

In  Gyn.  No.  2598  and  7810  the  i)ulse  was  irregularly  rai)id,  reaching  110 
on  several  occasions. 

In  Gyn.  No.  11111  convalescence  was  slow,  and  the  pulse  during  the  last 
nineteen  days  ranged  between  112  and  84. 

In  Gyn.  No.  6760  the  pulse  rose  to  130  on  the  second  day.  and  during  con 
valescence  ranged  loetween  110  and  90. 

In  Gyn.  No.  10300  the  pulse  innnodialcly  before  ojx'i'ation  was  90.  The 
evening  following  opei-ation  it  rose  to  162.  During  the  next  nin(^  days  it  gradu- 
ally drop))ed  to  100,  and  from  tliis  time  until  t lie  date  of  discharge  ranged  between 
100  and  90. 

The  two  cases  in  which  a  definite  cause  for  the  accelei'ation  couM  be  ;issigned 
were  (Jyn.  No.  10983  and  12583.  In  the  former  (he  i)ulse  immediately  lollowing 
oi)eration  rose  to  160.  It  eontimied  high  and  ii'regular,  ranging  between  116 
and  104  from  the  .sixth  to  the  thirty-second  day.  In  this  case  there  was  a  rather 
se\'ere  postopei'alix'e  hemorrhage,  the  details  of  which  are  coiisidci-ed  on  p.  51!). 

In  Gyn.  No.  12583  the  continucMl  r<apid  pulse  was  undouhledly  due  lo  the 
intestinal  obstruction  and  conunencing  i)ostoper;iti\-e  pei-itoiiilis. 

Hysterical  Manifestations.  In  Case  2710  a  myoma,  5  x  5  cm.,  .and  the  left 
lube  and  ox'ary  were  i'emo\'ed.  ( )n  hei-  admission  to  the  hospital  it  was  noted 
that  the  jjatienl.  who  was  forty  yeai's  old,  was  very  nerN'ous  .and  hyslei-ical. 
During  her  con\-alescence  she  had  s(n'eral  hystei'ical  att.acks,  but  these  in  no 
way  retarded  her  recoveiy. 


548  MYOMATA    OF   THE    UTERUS. 

The  patient  in  Case  7880  was  also  forty  years  old.  On  adirdssion  she  com- 
plained of  general  nervousness.  Several  myoniata  were  removed.  Her  con- 
valescence was  complicated  by  nervousness  of  an  extreme  type. 

In  Case  8250  the  jnitient  was  forty-two  years  old  and  comi)laincd  of  marked 
nervousness.  A  myoma,  altout  7  cm.  in  diameter,  was  removed.  Her  nervous 
condition  is  now  (six  years  after  operation)  even  worse,  and  her  own  life  and  that 
of  her  family  are  renderetl  miserable  by  her  morbitl  imaginations. 

It  will  be  noted  that  in  each  of  these  three  cases  the  nervous  phenomena 
antedated  operation,  and  that  the  extra  strain  of  operative  interference  merely 
served  to  accentuate  them. 

Excessive  Nausea  and  Vomiting. — In  Case  20.39  there  was  nuich  nausea,  but 
no  vomiting.  In  Case  10300,  11  myomata  were  removed;  the  .same  night  the 
pulse  reached  170,  and  nausea  persisted  until  the  seventh  day. 

The  nausea  in  Case  10497  persisted  for  four  days,  although  only  two  small 
myomata  had   been  enucleated. 

In  Case  4878  two  large  interstitial  myomata  were  removed,  and  a  dermoid 
cyst  was  resected  from  the  right  ovary.  Xau.^ea  and  vomiting  were  present 
for  five  days. 

In  Case  5801  several  myomata  were  enucleated.  During  convalescence 
there  were  two  attacks  of  nausea  and  vomiting.  The  patient  vomited  a  blood- 
stained fluid  each  time. 

In  Case  0.,  operated  upon  at  the  Ilebrcnv  Hos]ntal,  continuous  vomiting  per- 
sisted for  several  days,  the  Nomitus  sometimes  being  of  a  dark  chocolate  color. 
Such  vomiting  is  usually  followed  by  death.  As  seen  on  p.  ,551,  this  patient  had 
acute  nei:)hritis  and  extensive  sloughing  of  the  anterior  uterine  wall.  She  re- 
covered and  now,  five  years  later,  is  perfectly  well. 

Stercoraceous  vomiting  is  usually  indicative  of  obstruction,  and  is  always 
a  grave  sym])tom.  In  Case  2598  a  myoma  of  the  right  cornu,  together  with  the 
corresponding  tube  and  ovary,  was  removed.  The  patient  had  persistent  vomit- 
ing for  .'^ix  days.  At  this  time  the  stomach  was  washed  out  and  a  large  quantity 
of  stercoraceous  matter  came  away.     The  jiatient  recovered. 

A  reference  to  p.  533  will  give  a  tlescription  of  the  excessive  vomiting  noted 
in  fatal  cases. 

Postoperative  Hemorrhage. — We  include  here  only  those  cases  in  which, 
notwithstanding  the  hemorrhage,  the  patient  recovered.  In  two  cases  (Nos.  62 
and  10983)  secondary  hemorrhage  occurred.  In  the  first  case  the  bleeding  was 
slight  in  amount;  in  the  second,  \-ei-v  extensive. 


Gyn.  No.  62. 
H  e  m  o  r  r  h  a  g  e     V  olio  w  i  n  g     A  b  d  o  m  i  n  a  1     M  y  o  m  (>  c  t  o  m  y  . 
M.  S.   L.,  single,  white,  aged   thirty-three.     Admitted  November  28,   1889; 
discharged  February   1,   1890.     Operation.     A   myoma,   approximately   7  cm. 


ABDOMINAL    MYOMECTOMY.  549 

in  (lianiotor,  was  removed,  as  well  as  the  right  tube  and  ovary.  On  the  second 
day  there  was  slight  oozing,  necessitating  another  hgature  al^out  the  deep  sutures 
in  the  uterus.     The  patient  then  made  an  uneventful  recovery. 

Gyn.  No.  10983.     Path.  7192. 

Hemorrhage     Foil  o  ^^'  i  n  g     Removal     of     a     M  y  o  m  a  . 

C.  B.,  colored,  aged  thirty-two.  Admitted  January  9;  discharged  Febru- 
ary 11,  1904.  Operation,  removal  of  an  intraligamentary  myoma,  about  12  cm. 
in  diameter,  and  enucleation  of  several  nodules  from  the  posterior  wall.  After 
the  patient  reached  the  ward  it  was  noticed  that  the  abdominal  dressings  were 
markedly  stained.  Her  jnilse  rose  from  116  to  130.  An  hour  later  it  was  140. 
and  the  dressings  were  soaked  ^ith  bright-red  blood.  On  removal  of  one  stitch 
a  quantity  of  blood  filled  the  incision.  As  rapidly  as  possil)le  it  was  sponged  out. 
She  was  at  once  taken  to  the  operating  room,  and  the  incision  was  opened.  The 
abdominal  cavity  was  filletl  with  blood.  As  no  bleeding  point  calling  for  control 
could  be  found  in  the  uterus,  gauze  packs  were  placed  in  the  cul-de-sac  about  the 
uterus.  These  apparently  checked  the  oozing.  She  did  well  for  twelve  hours,  Init 
then  her  pulse  again  rose  to  140,  and  the  oozing  was  very  free.  The  abdominal 
incision  was  again  opened,  two  sutures  were  taken  in  the  top  of  the  uterus,  whence 
the  myoma  had  ])een  removed,  and  ten  minims  of  adrenalin  1 :  1000  were  ad- 
ministered hypodermically.  The  bleeding  was  entirely  checked,  and  from  this 
time  on  she  made  a  normal  convalescence.  Her  highest  postoperative  temper- 
ature was  100.8°  F.;  the  highest  pulse  w^as  160,  on  the  second  day.  She  was  dis- 
charged on  the  thirty-first  day. 

Intense  Abdominal  Pain  Following  Abdominal  Myomectomy. — Abdominal 
pain  is  a  natural  accomjjaniment  of  abdominal  operations,  l)ut  unless  intestinal 
obstruction  is  present  or  peritonitis  is  developing,  the  pain  is  usually  readily 
amenable  to  treatment.  In  only  one  of  our  cases  was  it  excessive.  In  Case 
11256,  the  patient,  forty-two  years  of  age,  had  a  myomatous  uterus  ext(>nding 
almost  to  the  umbilicus,  and  also  comi)lained  of  nervousness.  An  interstitial 
myoma,  15  cm.  in  diameter,  was  removed  at  the  patient's  recjuest.  Iler  liiglu'st 
postoperative  temperature  was  100°  F.,  and  from  a  i)Iiysical  standixiiiit  she  rallied 
reatUly,  but  for  nearly  a  week  she  complained  of  the  most  intense  agony.  The 
pain  was  relieved  by  various  simj)le  remedies.  It  was  with  the  greatest  dithculty 
that  she  could  be  ])ei'suaded  to  leave  h(M-  bed.  She  (iiially  left  tlie  lios]>ilal  oil  the 
thirty-seventh  day.  Three  years  later  she  was  still  e.\('essi\-ely  nervous,  and 
said  that  her  health  was  not  good. 

Such  a  case  might  \-ery  readily  mislead  the  operatoi-  into  reopening  the 
abdomen,  on  the  sup|)osition  that  obsti'uction  existed  oi-  th;it  peritonitis  was 
commencing. 

Postoperative  Cystitis. — This  not  iiirfe(|uent  coniplicatioii  following  ;in 
abdominal  operation  is  sometimes  undonbtedly  dne  to  carelessness,  but  in  other 
instances  occurs  without  any  appreciable  cause. 


550  MYOMATA    OF    THK    UTERUS. 

In  Case  8389  an  intorstitial  niyoina.  about  0  cm.  in  dianioter,  was  found  at  the 
junction  of  \\w  cervix  and  corj)us  on  the  left.  The  nodule  was  removed.  The 
patient  developed  a  severe  cystitis,  although  she  was  never  catheterized  in  the 
ward.  It  had  not  entirely  subsided  when  she  left  the  hospital,  and  although  her 
health  was  good  six  years  later,  she  still  suffered  from  "b(»aring-(lown  ])ains" 
in  the  vesical  region. 

In  Case  S4()2  many  myomata,  the  largest  7x7x14  cm.,  were  removed. 
Convalescence  was  complicated  by  a  cystitis.  The  ])atient  was  well  six  years 
later. 

In  Ca.se  ()7()2  a  myoma,  G  x  6  x  7.5  cm.,  lay  between  the  vesical  reflection  and 
the  uterus.  Catheterization  was  necessary  up  to  the  twenty-third  day  on 
account  of  retention.  A  cystitis  develo])ed  and  lasted  for  two  years.  At  present, 
eight  years  later,  there  is  no  bladder  disturl)ance,  but  the  ])atient  has  tabes 
dorsal  is. 

In  this  case  the  jx-rsistent  retention  was  an  undoubted  factor  in  the  causation 
of  the  cystitis,  and  in  the  removal  of  the  myoma  from  beneath  the  bladder  the 
ve.sical  blood-supply  may  ])ossibly  have  been  injured. 

Nephritis  Aggravated  by  Abdominal  Myomectomy. — In  Case  7753  a  myoma, 
3  cm.  in  diameter,  was  shelled  out,  a  hysterotomy  done  for  a  {polypoid  condition 
of  the  endometrium,  and  the  j)erineum  repaired.  Later  the  jmtient  was  trans- 
ferred to  the  medical  side  for  treatnuMit  for  a  chronic  nejjhritis.  The  ne])hritis 
had  been  i)i-es(Mit  before  the  operation,  and  it  is  interesting  to  see  how  much  a 
patient  can  sometimes  stand  even  when  the  kidney  function  is  impaired. 

The  acute  ne|)hritis  in  Case  0.  operated  uj)on  at  the  Hebrew  Hospital,  was 
e\i(h'ntly  ilue  in  pai1  to  the  acute  infection  following  the  sloughing  of  the  anterior 
uterine  walL  With  removal  of  the  necrotic  tissue  the  renal  symptoms  subsiih^d, 
and  the  patient   i'^  well  fi\-e  years  later. 

Free  Escape  of  Pus  from  the  Urethra. — In  Case  0474,  in  wliich  the  uterus  ex- 
tended foi-  two-thirds  the  distance  fi'om  the  i)ul)es  to  the  umbilicus,  a  large  inter- 
stitial myoma  was  removed  ])er  abdomen.  The  temperature  reached  103.2°  F. 
on  the  eighteenth  day,  and  a  persistent  phlebitis  developed  in  the  left  leg. 
Sixty  cubic  centimeters  of  pus  escaped  from  the  urethra.  Its  source  could 
not  be  definitely  ascertained,  but  possibly  it  came  from  a  small  peh'ic  abscess 
that  may  have  opened  into  the  bladder.  Such  an  evacuation  of  an  abscess  is 
well  instanced  in  Case  5350,  described  on  page  553. 

A  Foul  Uterine  Discharge  Following  Abdominal  Myomectomy. — In  Case  10394 
the  patient,  thirty-four  years  old,  had  a  submucous  myoma,  2.5x5x9  cm. 
A  drain  was  carried  down  through  the  ulei-us  to  the  vagina,  and  a  small  drain  left 
in  the  lower  end  of  the  abdominal  incision.  On  the  third  day  the  temperature 
reached  10;!°  I"'.,  and  on  the  i-enio\al  of  the  uterine  driiin  a  foul  discharge  came 
away.  ( )ii  the  nineteenth  day  the  |)atient  had  a  chill,  and  the  temperature  was 
104°  \'\ 

The  tumor,  on  removal,  was  found  to  be  lobulated,  dii-fy  gray  in  color,  and 


ABDO.MIXAL    MYOMECTOMY.  551 

had  a  foul  smell.  Histologic  examination  showed  an  acute  infiannnation. 
There  was  much  degeneration  of  the  tissue,  and  infiltration  with  ])olymorphonu- 
clear  leukocytes.  The  infection  from  the  degenerated  submucous  myoma 
readily  accounts  for  the  offensive  discharge.  The  patient  was  well  three  and 
one-half  years  later. 

In  CaseC.  H.I.  S.,  admitted  June  9,  1903,  a  soft,  cystic,  submucous  myoma, 
10  cm.  in  diameter,  was  removed.  On  the  sixth  day  the  tem))erature  reached 
103.6°  F.,  but  then  dropped  to  normal.  There  was  a  most  offensive  uterine  dis- 
charge.    The  patient's  health  was  fair  four  years  later. 

In  Case  0.,  operated  upon  in  the  Hebrew  Hospital,  nearly  all  the  anterior 
uterine  wall  came  away,  and  there  was  natui'ally  a  most  offensive  and  abundant 
uterine  discharge. 

In  each  of  these  cases  the  uterine  cavity  was  0])ened  up  at  operation,  and  in 
the  first  and  third  cases  the  cause  of  the  oft'ensive  discharge  was  readily  explained. 

Sloughing  of  the  Anterior  Uterine  Wall  After  Removal  of  a  Large  Interstitial 
Myoma. — In  this  case,  although  the  patient's  urine  contained  much  albumin,  we 
were  forced  to  operate  on  account  of  the  pressure  symptoms.  The  gloljular 
uterus  extended  almost  tothe  umbilicus.  During  removal  of  the  tumorthe  uterine 
cavity  was  slightly  opened.  Persistent  nausea  and  vomiting  followed  the  opera- 
tion, the  vomited  material  at  times  being  of  a  chocolate  color.  The  urine  con- 
tained much  more  albumin  and  many  casts  after  operation.  A  vaginal  dis- 
charge having  appeared,  the  cervix  was  split  and  quantities  of  the  necrotic  anterior 
uterine  wall  were  removed.  Had  it  not  been  for  this  evacuation  of  the  uterine 
contents,  the  patient  would  undoubtedly  have  died  of  infection. 

Why  the  anterior  wall  sloughed  it  is,  of  course,  impossil)le  to  determine  with 
certainty.  Opening  into  the  uterine  cavity  during  operation  naturally  ])rovides 
an  avenue  of  infection  if  the  uterine  cavity  contains  pus-organisms.  In  this 
case  also  the  nephritis  naturally  reduced  the  patient's  resistance. 

Had  it  not  been  for  the  fact  that  the  suture  line  in  the  uterus  was  brought  into 
intimate  contact  with  the  anterior  abdominal  wall  as  the  result  of  the  fixation 
(the  patient  being  near  the  menopause  and  single),  the  thin  and  rotten  shell  of 
the  anterior  uterine  wall  would  certainly  have  perforated  and  the  j)atient  died 
of  peritonitis. 

0.,  Hebrew  Hospital. 

Sloughing  of  the  Anterior  l'  t  e  r  i  ii  e  W  a  II  1'"  o  1  1  o  w  i  ng 
A  b  d  o  m  i  n  a  1   M  y  o  ni  e  c  t  o  m  y  . 

0.,  admitted  to  the  Hebrew  Hospital  .lul>-  II,  l'.t()2.  The  |.aliriit  had  been 
suffering  for  several  years  with  a  myomatous  uterus,  mid  toi-  the  last  lour  or  five 
days  her  legs  had  been  iiiai'kedly  swollen  and  she  liail  been  t'orced  to  i-emain  in 
bed.  The  urine  contaiiuMl  much  albumin  and  many  easts.  ( )])eration,  howe\'ei\ 
could  not  be  a\'oided,  as  there  wci-e  distinct  jii-essure  synij)Ioins.  W  hen  the  ab- 
domen was  ojx'iied,  a  myoma  was  found  extending  almost  to  the  umbilicus,  and 


552  MYOMATA    OF    THE    UTKRUS. 

situated  in  the  anterior  wall.  It  was  peeled  out  without  difRculty.  Tt  was 
fully  11  cm.  in  diameter,  and  there  was  a  good  deal  of  bleeding.  At  two  points 
the  uterine  cavity  was  opened.  The  cavity  was  clo.sed  with  catgut  sutures,  and 
the  uterus  firmly  fastt'iu'd  to  the  anterior  abdominal  wall.  The  appendages  were 
normal. 

July  17th:  Ever  since  operation  the  patient  has  l)een  vomiting.  The  vomi- 
tus  has  a  chocolate  color.  The  stomach  has  been  washed  out,  and  since  then 
the  nausea  has  been  much  less  marked.  To-day  the  |)ulse  is  better,  and  the 
])atient  shows  some  improvement.     The  urine  still  contains  many  casts. 

July  20th:  The  urine  contains  quantities  of  albumin  and  casts.  She  has 
improved  very  little  antl  for  the  last  few  days  has  been  delirious.  There  has  been 
a  most  offensive  uterine  discharge  for  several  days.  On  examination  under  anes- 
thesia we  found  fetid  pus  escaping  from  the  cervix.  On  stretching  the  cervix 
and  curetting,  only  a  slight  amount  of  tissue  came  away,  but  on  careful  examina- 
tion of  the  anterior  uterine  wall  where  the  myoma  was  situated,  and  on  making 
a  little  traction,  masses  of  necrotic  uterine  tissue  were  brought  away.  We  re- 
moved in  all  fully  a  large  handful  of  the  necrotic  uterine  wall,  without,  however, 
causing  any  hemorrhage.  To  insure  free  drainage  we  split  the  cervix  posteriorly 
back  as  far  as  the  internal  os,  and  controlled  all  bleeding  points  with  catgut. 
The  uterine  cavity  was  then  irrigated  thoroughly  and  packed  with  iodoform 
gauze.     The  })atient  made  a  gradual  recovery. 

July  1,  1907:     The  patient  is  in  excellent  health  five  years  after  operation. 

Pelvic  Peritonitis  Following  Abdominal  Myomectomy. — Where  there  have  been 
pelvic  adhesions  associated  with  a  myomatous  uterus  there  is  liable  to  be  slight 
pelvic  peritonitis  following  operation  if  all  oozing  is  not  checked  and  no  vaginal 
drainage  is  ])rovided  for. 

In  Gyn.  No.  5826  two  large  myomata  were  removed  from  the  uterus.  One 
of  the.se  was  partially  cov(>red  with  omental  adhesions.  After  the  operation  the 
patient  had  a  slight  bronchitis,  and  her  temj)erature  reached  101°  F.  At  the 
time  of  her  discharge  there  was  some  slight  induration  and  tenderness  in  the 
po.sterior  vaginal  fornix.  The  ])atient  was  well  nine  years  after  operation. 
Such  thickenings  often  disap])ear  spontaneously  in  a  short  time. 

In  Case  4537  a  colored  woman,  forty-two  years  of  age,  had  an  interstitial 
myoma,  5  x6  cm.,  and  a  tubo-ovarian  cyst,  which  was  densely  adherent  to  the 
posterioi-  .surface  of  the  uterus.  Both  were  renun'ed.  A  month  later  the  pvW'is 
was  o])ened  through  the  vagina  and  about  300  c.c.  of  encysted  sero-hemorrhagic 
fluid  came  away.  On  account  of  i^rolapsus  the  cervix  was  removed  and  the  ))ei-i- 
neum  repaii'ed.     The  ]iatient  was  in  fair  health  nine  and  one-half  years  later. 

Intestinal  Obstruction  Following  Abdominal  Myomectomy. — In  only  one  of 
our  280  abdominal  m\-()mectoinies  in  which  rec()\-ery  took  |)lace  did  we  have 
intestinal  obstruction.  In  (a.^e  125S3  the  patient  was  thirty-.seven  years  old. 
At  operation  the  left  appendages  were  liberated  from  adhesions,  and  the  right 
ai)pendages  removed  on  account  of  a  corpus-luteum  cyst;  two  interstitial  myo- 


ABDOMINAL    MYOMECTOMY.  553 

mata,  the  larger  2.5  cm.  in  diameter,  and  the  appendix,  which  was  sHghtly  con- 
stricted near  its  base,  were  also  removed.  On  the  third  day  signs  of  intestinal 
obstruction  developed.  When  the  abdomen  was  opened,  no  evidence  of  general 
peritonitis  could  be  found,  but  a  loop  of  gut  had  become  adherent  to  the  posterior 
surface  of  the  uterus.  The  intestine  at  this  point  was  thickly  coated  with  fibrin. 
Recovery  after  the  second  operation  was  uneventful.  The  patient  is  well 
eighteen  months  later. 

Where  obstruction  can  be  definitely  diagnosed  there  should  not  be  anv  delay 
in  opening  the  abdomen. 

For  the  fatal  cases  of  obstruction  see  p.  533. 

Leukocytosis  Following  Abdominal  Myomectomy. — Wien  a  purulent  accumu- 
lation is  present,  one  naturally  expects  to  find  an  increase  in  the  number  of  leu- 
kocytes. We  have  had  one  case  in  our  series,  however,  in  which  the  leukoc^^to- 
sis  developed  and  subsided  without  our  being  able  at  any  time  to  detect  the  i)uru- 
lent  focus.  In  Case  8773  the  patient  was  thirty-eight  years  old  and  single. 
Many  myomata  were  present,  thirteen  separate  incisions  being  made  through 
which  to  remove  them.  The  patient,  who  was  extremely  nervous  and  had  had 
fits  of  tlepression  prior  to  operation,  did  well  for  a  few  days  after  operation,  but 
from  the  eleventh  to  the  twenty-first  she  ran  a  temperature,  reaching  102.8°  F. 
on  the  fifteenth.  On  the  nineteenth  day  the  leukocytosis  reached  18,000.  She 
rapidly  imjjroved,  and  left  the  hospital  on  the  twenty-fifth  day  in  excellent  con- 
dition, and  with  the  nervous  dejiression  seemingly  relieved. 

Abscess  in  the  Broad  Ligament  Developing  After  Removal  of  a  Myoma. 
Spontaneous  Evacuation  into  the  Bladder. — In  the  following  case  a  large  intra- 
ligamentary  myoma  lay  partly  in  front  of  the  uterus,  but  chiefly  to  the  left,  be- 
tween the  peritoneal  folds.  Enucleation  was  easy,  but  closure  of  the  resultant 
space  difficult.  Several  days  after  operation  an  abscess  develo})e(l  in  the  space 
formerly  occupied  by  the  myoma,  and  soon  opened  into  the  bladder. 

In  this  case  it  would  have  been  ^\^ser  at  the  time  of  oi)eration  to  have  carried 
a  small  retroperitoneal  drain  from  a  point  just  above  Poupart's  ligament  down 
to  the  point  at  which  the  myoma  had  been  removed. 

Vaginal  drainage  was  not  attempted  earlier  on  account  of  the  danger  i^f  in- 
juring the  left  ureter  or  the  uterine  artery.     The  patient  was  well  ten  years  later. 

Gyn.  Nos.  5359  and  5560. 

Abscess  of  the  broad  ligament  d  e  v  e  1  o  p  i  n  g  after 
removal    of    a    myoma    (Fig.  329). 

L.  W.,  single,  aged  thirty-five.  Admitted  .lunr  27.  1S!)7:  discliargetl  Septem- 
ber 6,  1897.  Operation,  June  28,  1897,  myoniedoniy  and  suspension  of  the 
uterus.  A  myoma,  7x9x12  cm.,  was  shelled  out  of  the  left  broad  ligament 
(Fig.  329).  The  temperature  rose  steadily  after  operation,  reaching  104. (5°  F. 
on  the  fourth  day.  It  then  fell  slowly,  reaching  100°  !•".  on  the  ."sixteenth,  and 
becoming  normal  on  th(>  forty-eighth  day.     Several  days  after  operation  there 


554 


MYOMATA    OF   THK    UTERUS. 


^-^_  ^^^^ZU'* 


was  a  sudden  escajje  of  pin  from  the  liladder,  with  an  iin))rovenient  in  the  con- 
(Ution.  The  uriiu*  contained  (luantities  of  ])us  for  a  consi(lera])le  time.  Shortly 
afterward  the  jx'lvis  was  drained  throutrh  the  vaf^ina,  and  on  November  22,  1897, 
it  a<]i;ain  became  necessary  to  opiMi  the  pel\-is  through  the  vagina,  about  60  c.c. 
of  thin  grayish  pus  escaping.  On  January  14,  1898,  the  vaginal  opening  was 
again  (Hlated.  but  no  pus  came  away.  Tn  Xovember,  1900,  all  vestige  of  the 
former  trouble  liad  disappeared,  and  the  pelvis  was  absolutely  free  from  any 
thickening.     The  patient  was  perfectly  well  ten  years  after  oj)eration. 

Tonsillitis.     This  complication  is  a  by  no  means  rare  one.  j)articularly  in  old 

institutions,  and  the  sudden  rise  of  temj)erature,  especially  after  an  abdominal 

myomectomy,  ma}'  alarm  the  surgeon  until  the  cause  of  the  fever  is  ascertained. 

In  only  one  ca.se  (5873)  did  tonsillitis  de\-el())).     In  this  case  five  small  my- 

oniata  and  the  appendix  had  Ixh'ii  removed,  and  a  radical  cure  for  left  inguinal 

hernia  had  been  done  a  month  later.     Re- 
covery was  .satisfactory. 

Bronchitis. — The  anesthetic  employed 
in  the  early  years  of  the  tlepartment  was 
chloi'oform,  but  since  1894  ether  alone  or 
l)receded  by  nitrous  oxid  or  ethyl  chlorid 
has  been  the  anesthetic  in  conniion  use. 

In  two  out  of  the  280  succes.sful  cases 
a  bi-oiicliitis  de\-elope(l.  In  Case  8389  an 
interstitial  myoma,  about  6  cm.  in  diameter, 
was  removed.  The  patient  developed  a 
.severe  cystitis  and  a  slight  bronchitis, 
neilliei-of  which  was  absolutely  cured  when 
she  left  thehos|)ital. 

In  Case  o82()  two  fairly  large  myomata 
were    removed.     The  patient  developed  a 
marked  bronchitis  that  lasted  several  days. 
Pleurisy.     In  3  of  our  280  succes.sful  cases  pleurisy  occurred  during  convales- 
cence. 

In  Case  4415  a  wedge  of  adenomyomatous  tissue,  2x5  cm.,  was  excised  from 
the  posterior  uterine  wall.  During  convalescence  the  patient  had  phlebitis  and 
pleurisy  with  effusion.  With  the  develo])ment  of  the  pleurisy  the  temjjerature 
rose  to  102°  F.  The  patient  remained  well  for  two  years,  after  which  the  uter- 
ine hemorrhages  recurred. 

In  Case  8704  four  myomata  were  removeil.  ( )n  the  twelfth  day  the  j)atient 
complained  of  a  sharp  pain  at  the  lower  angle  of  th(>  right  scapula.  At  this 
point  there  were  im))aired  resonance  and  a  slight  friction  rub.  The  ))ulmonary 
dullness  disappeared  comi)letely  in  five  days. 

In  Case  1570  seven  myomata  were  i-emoved.  Convalescence  was  intei-rui)ted 
by  a  definite  attack  of  pleurisy,  with  effusion  in  the  right  chest,  accomj)anied  by 


Fig.  329. — \  .Myo.m.\  of  thk  Bkoad  Ligament. 
Gyn.  No.  .5.3.59.  The  myoma  lay  partly  be- 
tween the  bladder  and  uterus,  but  chiefly  in  the 
left  broad  listameiit.  .\fter  removal  of  the  my- 
oma per  abdomen  an  ab.scess  developed  in  the 
left  broad  ligament  and  opened  into  the  bladder. 


A BDOM I X AL    M YOIM ECTOM Y , 


555 


a  cough,  fulness  of  that  si(k>  of  the  chest,  and  a  temperature  of  102.2°  F.  l^leven 
years  later  the  patient  ''died  very  suddenly  from  hemorrhages — she  vomited 
blood."     The  letter  strongly  suggested  death  from  ])ulmonary  tuberculosis. 

Bronchopneumonia, — Tn  Case  11052  the  patient  was  twenty-seven  years  old. 
A  myoma,  o  cm.  in  diameter,  was  removed  from  the  fundus.  She  develojjed 
bronchopneumonia;  the  temperature  rose  to  104.5°  F.  on  the  second  day,  and 
slowly  dropped,  reaching  normal  on  the  eleventh  day.  The  subse<iuent  course 
was  uneventful. 

Lobar  Pneumonia. — In  Case  660  a  large  i)edunculated  myoma  and  the  left 
tube  and  ovary  were  removed  from  a  woman  thirty-six  years  old.  The  myoma 
was  enveloped  in  many  omental  adhesions.  The  temj)eratur('  on  tlie  s(H-on(l 
day  was  101.4°  F.,  but  below  101°  until  the  fourteenth  day,  when  she  had  a 
chill,  a  cough,  and  a  temperature  of  105.2°  F.  A  few  days  later  a  consolidation 
in  the  right  lower  lobe  was  made  out.     Finally  she  made  a  perfect  recovery. 

In  Case  8764  several  myomata  were  removed  and  the  uterus  was  suspended. 
The  patient,  a  white  woman,  aged  thirty,  on  the  thirteenth  day  complained  of 
.sharp  pains  at  the  lower  angle  of  the  right  sca])ula.  Resonance  was  imi)aii-ed, 
the  respiratory  sounds  were  harsh,  a  shght  friction-rub  was  detected,  and  later  a 
distinct  area  of  consolidation.  This  entirely  cleared  up  before  she  left  the 
hospital. 

Phlebitis  Following  Successful  Abdominal  Myomectomy. — From  the  accom- 
panying table  it  will  be  seen  that  in  six  out  of  280  cases  a  phlebitis  develoix'd. 
In  five  of  these  the  thrombosis  was  situated  in  the  left  leg.  In  Case  4415  the 
history  note  does  not  mention  which  leg  was  involved. 


PHLEBITIS  FOLLOWING  SUCCESSFUL  ABDOMINAL  MYOMECTOMIES. 

Cases. 

Size  of  Myomata. 

Onset. 

Location. 

12.504 

Four  niyf)inata,  Uirfz;est  4  cm.  in 
diameter. 

Seventeenth  day. 

L.  .sa]>li("n(His  vein. 

12028 

Several  small  myomata. 

L.  femoral  vein. 

10573 

Multiple  myomata,  largest  about 
7    cm.    in    diameter.      (Hemo- 
globin, 38  per  cent.) 

Seventeenth  day. 

L.  saphenous  vein. 

9.329 

Myoma,  3  cm.  in  diameter.     Re- 

pair of  complete  perineal  tear. 

Slight  phlebitis  in  left  leg. 

6474 

Myoma.  10  cm. 

Phlebitis  in  left   leg  obstinate. 

4415 

Adenomyoma;  remoxal  of  wedge 

Phk'i)itis      (side      not       noted). 

2  X  5  cm. 

Pleurisy. 

Bedsore  Following  Abdominal  Myomectomy. — In  Case  Mc.V.  (p.  512).  in  \vhi(di 
an  89-p()Uiid  myoma  was  rciiiovcd,  the  i)aruiit  had  rdciiia  of  the  bullocks  and 
legs.  On  account  of  marked  dyspnea  the  o|»('i'alioii  was  pcrfoinicd  willi  the 
jjaticnt  in  the  sitting  posture.  Notwithstanding  the  givalcsl  caiv  a  bedsore 
developed  a  few  daN's  after  operation,  it  ictai'detl  her  recoNcry  only  very 
slightly. 


556  MYOMATA    OF    TMK    TTHRUS. 

Abdominal  Operations  Necessary  Subsequent  to  Abdominal  Myomectomy. 
As  a  result  of  the  many  letters  sent  out  we  have  information  eoncernini!;  the 
greater  number  of  the  'iSO  myomectomy  ])atients.  with  the  followinii;  results: 

Cask. 

rj.')04.      Hi'lease  of  vesical,  intestinal,  and  ovarian  ailhesions 1 

7.')()().      Kelief  of  intestinal  obstruction 1 

2709i  +    .")t)8.").     Hei)eated  niyoniectomy 1 

4517         7073.     Removal  of  ovaries 2 

5359  +   5560.     Evacuation  of  pelvic  abscess 1 

706.4329,4925,  5076,    5846,   6760,   7779,    7886,   8220,    8936.    U.  P.  I.   +   C.  H.  I..  San.  No. 

1582,                     Hysterectomy, 12 

Total 18 

Release  of  Vesical,  Intestinal,  and  Ovarian  Adhesions. — In  Case  12504  a  myo- 
ma. 4  X  4  X  o  cm.,  was  removed  from  the  right  uterine  comu,  and  several  other 
very  small  nodules  were  .shelled  out.  The  appendages  were  normal.  Sixteen 
months  later  the  alxlomen  was  opened  on  account  of  pelvic  pain.  Fig.  330  shows 
the  findings.  The  Madder  was  adherent  to  the  anterior  surface  of  the  uterus. 
A  loop  of  small  bowel  was  partially  kinked  and  firmly  fixed  to  the  posterior  sur- 
face of  the  utei-us  on  the  I'ight  side,  and  also  firmly  glued  down  to  the  inner  edge 
of  the  right  ovary. 

This  case  demonstrates  clearly  the  danger  of  postoperative  adhesions.  It 
is  imj)o.s.siJ)le  to  i)revent  the  intestines  from  adhering  to  the  suture  line  in  the 
utems  if  the  myoma  is  situated  in  the  ])osterior  wall  of  the  utcu'us.  When 
located  in  the  anterior  wall,  suspension  of  the  uterus  will  often  cover  in  the  raw 
area  completely. 

Gyn.  No.  12504. 

A  b  d  o  m  i  n  a  1  m  y  o  m  e  c  t  o  m  y  .  S  11  b  s  e  ([  u  e  n  t  o  ]>  e  rati  o  n 
for  release  of  vesical,  intestinal,  and  o  v  a  r  i  a  n  a  d  - 
h  e  s  i  o  n  s    (Fig.  330). 

A.  8.,  single,  aged  thirty-eight,  white.  Admitted  November  10,  1905;  dis- 
charged thirty-two  days  latei'.  A  myoma,  4  cm.  in  diameter,  was  removed  from 
the  vicinity  of  the  right  uterine  horn,  and  the  opening  closed  with  through-and- 
through  sutures  of  plain  catgut:  other  small  niN'omata  were  also  enucleated. 
On  the  seventeenth  day  the  ])atient  complained  of  ])ain  in  the  left  leg,  with  some 
swelling.  On  November  1(5.  1007,  the  abdomen  was  again  opened.  We  re- 
moved the  appendix,  which  was  enlarged  and  injected.  There  were  numerous 
adhesions  to  the  a.scending  colon.  The  bladder  was  drawn  up  o\-er  the  anterior 
surface  of  the  uterus  (Fig.  330).  The.se  adhesions  were  easily  liberated.  A  loop 
of  small  bowel  was  adherent  to  the  ])()stei"ior  surface  of  the  uterus  by  numerous 
exceedingly  va.scular  adhesions,  which  were  also  easily  se})arated.  and  the  same 
loop  was  adherent  to  the  right  ovary  over  an  ar(>a  1.5  cm.  in  diameter.  Th(>  re- 
lation between  the  ovary  and  the  bowel  was  an  exceedingly  intimate  one.     After 


ABDOMINAL   MYOMECTOMY, 


557 


loosening  up  adhesions  we  found  that  the  outer  coat  of  the  bowel  had  ])een  sac- 
rificed to  a  slight  extent.  The  raw  surfaces  w^re  approximated  with  Pagen- 
stecher  sutures. 

This  complication  is  of  great  interest.  At  the  previous  operation  the  uterus 
was  free  from  adhesions  and  the  appendages  were  normal.  The  intestine  had 
undoubtedly  become  adherent  to  the  uterus  over  the  area  of  the  myomectomy, 
probably  as  the  result  of  the  irritation  produced  by  the  ends  of  the  catgut  su- 
tures.    Whv  the  intestine  became  adherent  to  the  ovary  it  is  im])ossible  to  say. 


Fig.  330. — Pelvic  Adhesions  Following  Abdomin.\l  Mvomecto.mv. 
Gyn.  No.  12504.     This  was  the  condition  found  sixteen  months  after  a  myoma,  4  cm.  in  diameter,  had  lieen 
removed  from  the  vicinity  of  the  right  uterine  cornu.     Several  other  small  nodules  were  also  enucleated.     The 
bladder  is  adherent  to  the  anterior  surface  of  the  uterus.     A  loop  of  small  bowel  was  firmly  fixeil  to  the  posterior 
surface  of  the  uterus,  and  also  to  the  riglit  ovary. 


Intestinal  Obstruction  Following  Years  After  Abdominal  Myomectomy.  —\\'(> 

have  had  one  case  of  this  character.  In  1SS()  a  conscrvntivc  \)r]\\r  oitci-atioii,  of 
the  nature  of  which  we  know  nothing,  was  |)ert'oniic(L  i'ouilccti  ycais  lalcrthe 
patient  entereil  the  .hihiis  lIo])kins  llosi)ital  aiul  a  iiiyoni.-i,  thivc  times  the  size 
of  the  uterus,  was  removed.  Intestinal  adhesions  wei'e  reh'.-ised,  ;m(l  the  uleius 
was  sus])eiide(L  The  follow  ing  year  another  surgeon  ivmoxcd  the  ;i|)])en(li\,  and 
subseciiiently  had  to  ojK'ii  the  abdomen  for  obst  ruction,  releasing  nian\-  adhesions, 
and  resecting  a  portion  of  the  small  bowel.  .\  lew  months  ag(»  the  patient  had 
typhoid  fever.     Jn  .lanuaiy,  lUO",  she  reporte(l  th.it  hei-  health  was  not  good. 


558  MYOMATA    OF   THE    UTERUS. 

Ill  this  case  tho  iiiyoiiicctoiuy  was  in  no  way  responsible  for  the  adhesions,  as 
these  were  present   hct'orc  the  ojieration. 

Gyn,  No.  7566. 

A  1)  (1  (I  111  i  n  a  1  ni  y  o  ni  e  c  t  o  ni  y  w  i  t  h  sub  s  e  (j  u  e  n  t  r  e  ni  oval 
of  the  appendix:  later  d  e  n  s  e  a  d  h  e  s  i  o  n  s  producing 
intestinal  obstruction  and  requiring  resection  of 
t  h  e    1)  o  w  (■  1  .       H  e  c  o  v  e  r  y  . 

-M.  F.,  white,  single,  aged  forty.  Admitted  February  10 ;  discharged  March 
10,  1900.  She  said  that  a  conservative  abdominal  operation  had  been  done  four- 
teen years  before,  the  nature  of  which  we  do  not  know.  At  operation  various 
intestinal  adhesions  were  released,  a  myoma  was  removed  from  the  uterus,  and 
the  uterus  .suspended.  The  uterine  tumor  was  about  the  size  of  a  two  months 
pregnant  organ.  The  tubes  and  ovaries  were  not  diseased.  In  a  letter  re- 
ceived from  hci'  seven  years  later  she  states  that  in  the  following  year  her  appen- 
dix w-as  i-emoved,  and  that  later  on,  on  account  of  dense  adhesions  and  intestinal 
obstruction,  it  was  necessary  to  open  the  abdomen  again  and  remove  a  portion 
of  the  small  intestine.     In  1906  she  had  typhoid  fever. 

Repeated  Myomectomy. — In  one  case  in  which  a  myoma  was  situated  in  the 
left  cornu,  the  cornu  and  the  left  appendages  were  removed  after  liberation  of 
many  adhesions.  Three  and  a  half  years  later,  after  release  of  adhesions,  two 
small  myomata  were  removed  from  the  anterior  Avail  of  the  uterus. 

Gyn.  Nos.  2'jog\  and  5635. 

C.  B..  aged  fifty-six,  white,  widow.  Admitted  April  9;  discharged  .May  5, 
1S94.  A  myoma,  o  x  0  x  7.5  cm.,  was  removed  from  the  left  cornu.  Pelvic 
adhesions  were  liberated,  and  the  left  tul)e  and  ovary  were  removed. 

The  patient  returned  to  the  hospital  (No.  5635)  on  October  27,  1897,  and  was 
discharged  November  24th  of  the  same  year.  The  operation  this  time  consisted 
of  a  myomectomy  with  removal  of  the  right  tube  and  ovary.  Adhesions  were 
present  between  the  uterus  and  omentum,  .small  intestine,  and  bladder.  Two 
small  myomata  were  removed  from  the  anterior  wall  of  the  uterus  near  the  cervix. 
The  patient  made  a  good  recovery. 

Removal  of  Ovaries  Subsequent  to  Myomectomy. — In  Case  4517  four  small 
niyomata  were  removed  and  the  ulerus  was  suspended.  The  appendages  were 
normal.  About  ten  years  later  she  had  another  abdominal  operation,  of  the 
character  of  W'hich  .she  knows  nothing.  A  few  inoiitlis  later  she  had  her  oN'aries 
I'emoved,  for  what  reason  we  do  not  know. 

In  Case  7073,  after  release  of  the  adherent  ajjpendages,  an  inteistitial  myoma, 
/  cm.  in  diameter,  was  removed.  A  few  months  latei'  she  came  under  the  care 
ol  another  ])hysician.  and  her  ovaries  wei'e  iviuovimI,  with  tempoi-ary  benefit. 


ABDOMINAL    MYOMECTOMY.  559 

Gyn.  No.  4517. 

R  e  m  o  \'  a  1   o  f   o  \'  a  r  i  v  s   a  f  t  c  r  m  y  o  111  c  c  t  o  111  y  . 

E.  T.,  single,  aged  thirty-nine.  Admitted  July  17;  discharged  August  16, 
1896.  Operation,  July  18th.  Myomectomy  and  suspension  of  the  uterus.  Four 
small  myomata  were  enucleated.  The  appendages  were  normal.  On  June  10, 
1907,  we  received  a  communication  from  the  patient  saying:  ''The  operation  did 
but  little  good.  It  only  patched  me  up  for  about  a  year.  From  then  on  I  have 
been  a  great  sufferer."  Last  year  she  had  an  o])eration  ])erf()rmed  at  another 
hospital,  and  in  April  of  this  year  had  her  ovaries  removed.  Thcnr  condition  we 
do  not  know.  Of  course,  in  this  case  it  is  quite  possible  that  the  adhesions  of 
the  ovary  were  in  no  way  the  result  of  the  previous  operation,  especially  as  the 
patient  remained  well  for  the  first  year. 

Gyn.  No.  7073. 

M  y  o  m  e  c  t  o  in  y      \\-  i  t  h      s  u  b  s  e  ci  u  e  n  t      removal     of      t  h  e 
ovaries. 

M.  S.  H.,  aged  thirty-six,  white,  married.  Admitted  July  13:  discharged 
August  22,  1899.  Operation,  myomectomy  with  release  of  adherent  tubes  and 
ovaries;  suspension  of  the  uterus.  The  myoma  was  subvesical.  After  its  re- 
moval a  good  many  sutures  were  necessary  on  account  of  the  bleeding  from  the 
stitch  holes. 

April  29,  1907:  A  letter  from  Dr.  A.  F.  Brant,  of  Heathsville,  ^'a.,  says 
that  the  patient  experienced  little  relief  from  the  operation.  She  returned  to 
another  hospital  within  a  few  months  and  had  both  ovaries  removed. 

Of  course,  in  this  case  the  adhesions  in  the  pelvis  already  existed.  An  at- 
tem])t  was  made  to  rectify  matters  without  sacrificing  the  organs. 

Evacuation  of  a  Pelvic  Abscess  Months  After  a  Myomectomy. — In  C  asc  5359. 
in  which  a  broad  ligament  myoiiia  was  rem()\'c(l,  an  abscess  developed.  This 
()])(Mied  into  the  bladder.  Hcfoi'c  the  ])atieiit  left  the  hospital  it  was  n(>c(>ssary  to 
drain  the  peU'is  thi'oiigh  the  \'agina,  and  on  se\-ei-;il  occasions  after  she  lett  the 
hospital  it  was  found  expedient  to  reestablish  the  peUic  ch'ainage.  This  case  is 
repoi-te(l  in  full  on  p.  ^)^)'.]. 


Hysterectomy  Subsequent  to  Abdominal  Myomectomy. 
In  the  following  pages  several  cases  are  desci'ibed  in  which  remo\-al  of  the 
uterus   became  necessary  later.     These  cases  natui'ally   fall    into   two   delinite 
gi'oujjs: 

1.  Hysterectomy  on  account  of  pehic  adhesions. 

2.  Hysterectomy  on  account  of  tiie  de\-elo])ment  of  other  myomata. 
Hysterectomy  on  Account  of  Postoperative  Adhesions. — Cases  5076,  oSKl,  aiul 


560  MVOMATA    OF    THE    UTERUS. 

San.  1582  bi'loii-j;  to  this  iiroup.*  In  Case  5()7()  an  interstitial  myoma,  6  x  7.5  x  9 
cm.,  was  removed,  antl  portion.s  of  both  ovaries  were  resected  on  account  of  an 
ovaritm  cyst.  Two  years  hiter  Dr.  George  Ben  Johnston,  of  Richmond,  found  it 
necessary  to  i-ciiiove  the  uterus  and  appendix. 

In  Case  5S4()  a  reference  to  tlie  history  shows  that  a  myoma,  2  cm.  in  diameter, 
was  removed,  and  jx-lvic  adliesions  were  reh-ased.  Five  years  hiter  hysterectomy 
was  done  for  pelvic  adhesions. 

The  uterus  in  San.  1582  contained  a  myoma,  4  cm.  in  diameter;  this  and  the 
appendix  wei-e  removed.  Later  a  hysterectomy  was  reijuired  on  account  of 
tlense  ix'lvic  adhesions,  probably  gonorrheal  in  origin. 

Adhesions  may  be  due  to  so  many  diffen^nt  causes  and  are  so  freciuently 
associated  with  myomata  before  o|)eration  that  it  is  difficult  to  attribute  pelvic 
adhesions  to  the  myomectomy  unless  the  adhesions  are  chiefly  around  the  uter- 
ine incisions  from  which  the  tumors  have  been  enucleated,  and  even  then,  where 
adhesions  have  once  existed,  there  seems  to  be  a  marked  tendency  for  them  to 
reform. 

Gyn.  No.  5076. 

A  b  d  o  m  i  n  a  1  m  y  o  meet  o  m  y  w  i  t  h  s  u  1)  s  c  q  u  c  n  t  h  y  s  t  e  - 
recto  m  y    o  n    a  c  c  o  u  n  t    of    pelvic    adhesions. 

M.  ('.,  white,  married,  aged  forty-five.  Admitted  March  7;  discharged 
April  20,  1897.  Ui)(Tation,  March  Sth,  myomectomy ;  cystectomy.  An  elliptic 
incision,  6  cm.  long,  was  made  in  the  anterior  wall  of  the  uterus,  and  an  interstitial 
myoma,  6  x  7.5  x  9  cm.,  enucleated.  A  Graafian-follicle  cyst  of  the  right  ovary 
was  dissected  out.  On  February  21,  1907,  w^e  received  the  following  letter  from 
the  patient:  "My  health  was  not  improved  by  my  stay  in  the  Johns  Hopkins 
Hospital.  Two  years  later  I  went  to  Dr.  Ben  Johnston,  of  Richmond,  who  re- 
moved the  uterus  and  api)en(lix." 

Gyn.  Nos.  5846  and  10183. 

A  1)  d  o  m  i  n  a  1  m  }•  o  m  e  c  t  o  ni  y  w  i  t  h  s  u  b  sequent  li  y  s  t  e  r  - 
e  c  t  o  m  y     on     a  c  c  o  u  n  t     o  f     a  d  h  e  s  i  o  n  s . 

1^.  F.  A.,  white,  aged  thirty-three,  married.  Admitted  Fe])ruary  4;  dis- 
charged .March  4,  1898.  Operation,  February  5,  1898.  Two  small  vaginal  cysts 
were  removed,  a  subperitoneal  myoma  2  cm.  in  diameter  was  enucleated, 
pelvic  adhesions  were  freed.  an<l  the  uterus  was  suspended. 

Gyn.  No.  10183.  For  two  years  after  leaving  the  hospital  the  patient  was  in 
very  good  health,  ])ut  during  the  last  three  years  there  has  been  a  gradual  in- 
crease in  the  menstrual  discluirge.  Now  the  jiatient  is  in  bed  most  of  the  time. 
She  has  a  great  deal  of  pain,  especially  in  the  left  side. 

*  In  Gyn.  No.  S220,  after  liberation  of  the  adhesions,  two  small  myomata  were  removed  from 
the  uterus.  Examination  of  the  scrapings  (Path.  No.  440.3)  showed  tuberculosis.  Four  months 
later  the  uterus  was  removed  on  account  of  the  tulxTculosis.  The  hysterectomy  was  in  no  way 
rendered  necessary  by  the  myomata. 


ABDOMINAL    MYOMECTOMY.  561 

January  14,  19Uo:  Abcloniiiial  In-.sterecloiny  on  account  of  somewhat  dense 
adhesions. 

Hysterectomy  on  Account  of  the  Development  of  Other  Myomata. — The 
following  cases  are  of  some  interest,  inasmuch  as  they  not  only  show  the  num- 
ber of  myomata  that  may  develop  after  a  myomectomy,  but  also  enable  us  to 
determine  with  relative  accuracy  the  rate  of  growth  of  some  of  the  in}-(jmata. 

Often  during  a  myomectomy  minute  white  specks  are  seen  either  on  the  sur- 
face or  in  the  musculature  of  the  uterus.  These  are  usually  myomata,  not 
over  0.5  or  1  nmi.  in  diameter,  and  may  be  readily  overlooked. 

Fortunately,  relatively  few  of  our  patients  have  required  a  secondai-y  liyster- 
ectom}'. 

In  Case  706  (also  1033  and  S41o)  a  small  subperitoneal  myoma  situated  near 
the  cervix  was  removed  in  1S91.  Ten  j^ears  later  the  uterus  was  (everywhere 
studded  with  small  myomata  and  filled  the  pelvis.  Hysterectoni}'  was  per- 
formed. 

In  Case  4925  (also  9439)  an  interstitial  nodule,  12  x  21  x  27  cm.,  was  removed. 
Fifty  catgut  sutures  were  necessary  to  close  the  resultant  space.  Five  years 
later  the  uterus  seen  in  Fig.  331  (p.  562)  was  removed. 

Case  7779  (also  12689)  affords  a  very  interesting  example  of  the  sub- 
sequent development  of  large  myomata.  A  subperitoneal  myoma,  9  x  10  x  12 
cm.,  and  several  smaller  ones,  were  removed  in  1900  (Fig.  332).  A  little  less 
than  six  years  later  the  uterus  was  again  enlarged,  measured  12  x  13  x  16  cm., 
and  contained  numerous  myomata.  These  were  subperitoneal,  interstitial, 
and  subnuicous,  the  last  of  large  size  (Fig.  333  p.  564).  Hysterectomy  was 
performed. 

In  Case  7886  a  pedunculated  myoma,  aljout  7  cm.  in  diameter,  and  several 
small  interstitial  nodules  were  removed  in  1900.  About  six  years  later  hyster- 
ectomy was  performed,  chiefly  on  account  of  dense  adhesions  between  the  uterus 
and  surrounding  structures.  The  uterus  contained  three  small  myonuita,  the 
largest  1  cm.  in  diameter.  There  was  also  some  diffuse  thickening  of  the  inner 
muscular  layers  of  the  uterus,  with  early  adenomyoma. 

The  left  ovary  and  a  myoma  were  removed  in  Case  8936  in  1896.  Five 
years  later  hysterectomy  was  performed  on  account  of  dense  i)elvic  lesions  and 
interstitial  and  subiimcous  myomata. 

In  U.  P.  I.  Case  (!.,  fiNc  inlcrstilial  iiiyoiiiala,  the  largest  5  cm.  in  diameter. 
were  removed.  Seven  and  a  h;df  years  later  (C.  H.  1.  Case  G.)  tiie  uterus  was 
densely  adherent  antl  contained  several  myomata.  Hysterectomy  was  per- 
formed. 

Judging  from  these  cases  only,  one  w'oukl  doubt  the  wisdom  of  doing  a  myo- 
mectomy, but  the  cases  recpiiring  a  second  o))ei\'ition  foi'ni  a  small  percentage 
of  the  total  number. 
3G 


562 


MVO.MATA    OF    THE    UTERUS. 


Case  706  (1033  and  8415). 

A  b  d  0  m  i  II  a  1  111  y  o  111  c  c  t  o  111  y  w  i  t  li  s  u  b  s  0  q  11  e  n  t  h  y  s  t  c  r  o  - 
111  y  o  111  c  c  t  0  111  y  . 

This  patient  entered  the  liosjutal  on  April  2S,  bS<)l,  when  a  (Ulatation  and 
curettage  was  done.  She  returned  to  the  hospital  (1033)  oil  October  2Sth  of  the 
same  year,  when  a  cervical  myoma.  2x  1.5  cm.,  was  removed  from  the  uterus 
throup;h  an  abdominal  incision. 

Gyn.  No.  S415.  A^ain  admitted  December  29,  1900.  On  vaginal  examin- 
ation the  cervix  was  found  to  be  normal  in  size  and  in  good  position.  Numerous 
nodules  tilled  the  j)elvis.  The  uterus  Inilged  forward.  ])ushing  outward  the  an- 
terior vaginal  wall.  .\  hysterectomy  was  done.  The  j)atient  made  a  jjcrfectly 
satisfactorv  reco\-erv. 


Fio.     331. — .-Vppearaxce  of  a  Uterus  Five  Years  after  Removal  df  a  I.akce  Interstitial  Myoma,      if;  nat. 

size.) 
Gyn.  No.  9439.  Path.  No.  .5640.  Five  years  ago  an  interstitial  myoma,  12  x  21  x  27  cm.,  was  removed. 
The  appendages  and  the  cervix  are  normal.  The  scar  on  the  anterior  surface  of  the  uterus  shows  clearly  some 
of  the  transverse  suture  lines,  and  at  the  upper  end  of  the  scar  is  an  oval  area  showing  where  the  uterus  was  at- 
tached to  the  anterior  abdominal  wall.  The  enlargement  in  the  fundu.s  is  caused  by  several  myomata,  and  pro- 
jecting from  the  fundus,  near  the  right  tube,  is  a  large  myomatous  nodule.  See  Fig.  60.  p.  77.  for  the  appearance 
f)f  the  uterus  at  the  first  oi)eration. 

Path.  No.  4595.  The  sjx'ciinen  consists  of  tiie  uterus,  which  is  aj)proximately 
13  X  10  X  11  cm.  Surrounding  it  on  all  .sides  are  myomata,  se.ssile  and  })eduncu- 
lated.     It  also  contains  interstitial  and  submucous  nodules. 


Gyn.  Nos.  4925  and  9439. 

^I  }•  o  in  e  c  t  o  111  y    w  i  t  li    h  }•  s  t  e  r  o  m  }•  o  111  e  c  t  o  m  y   five    y  e  a  r  s 
later  (Fig.  331). 

S.J.  L.,   white,   sinde,  anoil   fortv-thr(M'.     .Xdmitteil  Januarvfj;  discharged 


ABDOMINAL    MYOMECTOMY. 


563 


January  28,  1897.  Oi)eration,  January  9,  1897,  niyoniectoniy.  The  uterus  was 
twisted  to  an  ano;le  of  90  degrees  (Fig.  60,  p.  77).  It  contained  one  myoma 
12x21  X  27  cm.,  in  the  anterior  wall.  The  resultant  space  was  closed  witli  .')() 
catgut  sutures. 

Gyn.  No.  9439.  The  jjatient  was  readmitted  March  3,  1902,  and  operated 
upon  on  March  5th,  a  complete  hysterectomy  and  appendectomy  being  per- 
formed. As  soon  as  the  abdomen  was  opened  the  scar  of  the  old  myomectomy 
was  seen  on  the  left  anterior  surface  of  the  fundus  (Fig.  331).  The  fundus  itself 
was  greatly  enlarged,  especially  to  the  right,  and  there  was  a  rounded  tumor 
in  the  right  cornu.  The  first  glance  at  the  specimen  suggested  a  uniformly  en- 
larged bicornate  uterus.     The  patient  made  a  perfectly  satisfactory  recovery. 

Path.    No.    5640.     The  specimen    consists  of    the    entire   uterus  with    the 
appendages.      Its    general    form    is 
seen  in  Fig.  331. 

Gyn.  Nos.  7779  and  12689. 

A  b  d  o  m  i  n  a  1  m  }■  o  m  e  c  - 
t  o  m  y  with  h  y  s  t  e  r  o  m  y  o  - 
m  e  c  t  o  m  y  nearly  s  i  x  y  e  a  r  s 
later    (Figs.  332  and  333). 

R.  W.,  aged  thirty-one,  white, 
single.  Admitted  April  30;  dis- 
charged May  26,  1900.  Operation, 
May  3,  1900,  myomectomy.  The 
largest  tumor  was  situated  in  the 
posterior  wall  of  the  uterus,  and 
was  very  offensive,  apparently  under- 
going degeneration.     Several    other 

smaller        myomata       were       removed         peritoneal  nodule  projecting  from  the  posterior  i 

tlie  uterus  measured  1)  X  10  X  12  cm.     ProjectiiiK 
from    various    portions   of    the   uterus         fundus,   and    also   from    the   anterior   surface,    are    other 
(Fig.     332).       The     l);lti("llt     made      an         «'"'^"  ""d"l«s.     For  the   appearance  of  the  uterus  aU.ut 
^       "  1  SIX  years  later  see  r  IR.  m3- 

uninterrupted  recovery. 

Path.  No.  4038.  The  large  myoma  measures  9  x  10  x  12  cm.  Its  surface  is 
rough  and  shaggy,  and  on  section  presents  an  area  of  degeneration  consisting 
of  a  soft  disintegraliiig  mass. 

Gyn.  No.  12689.  Readmitted  February  10,  1906.  The  i)atient  had  some 
discomfort  for  a  year  following  the  previous  operation,  but  remained  perfectly 
well  for  four  years.  A  few  months  ago  she  began  to  have  pain  in  the  iliac  fossa 
and  in  the  hip,  aching  in  character.  ( )ne  month  ago  the  menstruation  lasted 
nearly  thirty  days. 

Operation,  panhysterectomy.  The  peritoneal  surface  of  the  uterus  was 
everywhere  smooth.  There  was  one  small  band  of  adhesions  from  the  pelvic 
wall  to  the  region  of  the  left  ovary.  On  superhcial  examination  there  were  no 
signs  whatever  of  the  previous  operation.     The  patient  made  a  perfect  recovery. 


Fig.  332. — Myom.\t.\    REiViovED    by     Abdo.minai.    Myo- 
mectomy. 
Gyn.     No.  7779.     Path.  No.  4038.     The  large  sub- 
surface of 
from  the 


564 


MYOMATA    (IF    TIIK    ("TKIU'S. 


l\ith.  No.  OooS.  The  iitciiis  is  1")  ciii.  in  lentil li.  \'.\  cm.  in  hi'cadth,  and  112  cm. 
in  its  anteropostci-ior  diainoter  (Fig.  333).  Attaclicd  to  one  \)o\u\  is  a  small 
tag  of  omentum.  Pi-ojectiiig  from  the  posterior  surface  is  a  pedunculated 
myoma.  2..')  \  1  ..">  em.  Tlie  enlargement  in  the  uterus  is  due  chieHy  to  one  large 
and  several  smaller  suhmucous  myomata.     The  large  myoma  is  9  cm.  across. 

This  case  is  particularly  interesting,  as  it  shows  the  possible  developments  in 
the  course  of  six  years. 


ut    Cavity      ^(((^•A\' 


Fig.  333. — A  Utekus  .\noL t  Six  \'k.\k.s  .Vi-tkh  Audo.minal  Kkmh\  al  of  all  Mv().\l\ta  that  Could  be  Detecfed. 

(|  nat.  size.) 
Ciyn.  No     126S9.     Patli.   No.  'Joi>!S.     The  uterus  measures   lo  x  13  x  12  rni.     The  cliief    increase  in  size  is 
caused  by  submucous  myomata.     The  appendages  are  normaL     For  ihc  appcar;ince  of  the  uterus  when  myomec- 
tomy was  performed  nearly  six  years  before  see  Fig.  332. 

Gyn.  No.  7886.     San.  No.  2178. 

A  lid  o  m  i  n  a  1  m  y  o  m  e  c  t  o  m  y  foil  o  \v  e  d  six  y  e  a  r  s  1  a  t  e  r  h  y 
h  y  s  t  e  V  o  m  y  o  m  e  c  t  o  m  y  . 

C.  S.,  aged  forty,  white,  married.  Admitted  June  0:  discharged  July  7, 
1900.  Operation,  inulti])le  myomectomy.  .\  myoma  7  cm.  in  diameter  was  re- 
moved from  the  ])osterior  surface  of  the  uterus,  and  several  smaller  scattered 
ones  were  also  enucleated.  Com-alescence  was  complicated  by  ner\-ousness 
of  an  extreme  type. 

San.  No.  2178.     The  jjatient  was  readmitted  on  May  2,  190G.     In  addition 


ABuu.MixAL  :myu.mkctumy.  565 

to  the  myomatous  uterus,  there  were  marked  adhesions  around  the  left  tube 
and  ovary  and  to  the  surrounding  structures.  The  rectum  and  intestines  were 
slightly  adherent  on  the  right  side. 

Path.  No.  9803.  The  uterus,  both  antei-ioi'Iy  and  posteriorly,  is  enveloped 
in  adhesions.  It  is  very  little  increased  in  size,  and  contains  three  myomata, 
the  largest  1  cm.  in  diameter.  The  right  tube  is  bound  down  to  the  uterus.  Its 
fimbriated  end,  however,  is  free.  The  ovary  is  Httle  altered.  The  left  tube 
and  ovary  show  few  adhesions,  but  the  fimbriated  end  of  tiie  tube  is  normal. 
Microscopic  examination  in  this  case  shows  commencing  adenomyomatous 
formation  in  the  body  of  the  uterus. 

Gyn.  Nos.  8936  and  9203. 

M  y  o  m  e  c  t  o  m  y  foil  o  \v  e  d  b  y  a  b  d  o  m  i  n  a  1  h  y  s  t  e  r  e  c  - 
t  o  m  y  . 

S.  B.,  aged  thirty-six,  white.  Admitted  July  22,  1901.  Five  years  before 
the  patient  had  been  operated  on  for  sterility,  and  at  that  time  a  myoma  was 
removed  from  the  body  of  the  uterus,  and  the  left  ovary  also  extirpated.  The 
patient  on  admission  was  extremely  pale;  the  hemoglobin  was  15  per  cent. 
She  remained  in  the  hospital  for  some  time,  and  was  sent  home  to  recuperate. 

She  was  readmitted  on  November  9,  1901,  and  discharged  on  December  7, 
1901.  Her  hemoglobin  had  risen  to  46  per  cent.  In  the  lower  part  of  the 
abdomen,  on  the  left  side,  was  a  hard  mass  made  up  of  two  distinct  nodules 
that  reached  half-way  to  the  umbilicus.  This  was  very  movable  and  tender. 
Operation,  November  11,  1901,  hysteromyomectomy;  removal  of  th(>  right  tube 
and  ovary;  cure  of  ventral  hernia.  The  sigmoid  was  densely  adherent  to  the 
posterior  wall  of  the  fundus.  This  was  cut  free  by  leaving  the  outer  sheath  of 
the  myoma  and  round  ligament  against  the  intestines.  On  the  right  side  the 
pus-tube  and  cystic  ovary  were  gradually  pulled  out  of  their  l)ed  of  adhesions. 
The  patient,  on  her  discharge,  had  a  hemoglobin  of  75  per  cent. 

U.  P.  I.,  G.,  also  C.  H.  I.,  G. 

M  y  o  m  e  c  t  o  m  y  w  i  t  li  sub  s  e  (j  u  e  n  t  d  e  a'  e  1  o  ))  ni  e  n  t  of 
other    m  y  o  m  a  t  a  . 

This  patient  was  seen  in  consultation  with  Dr.  Thomas  bintliicuni.  Sa\age. 
Md.,  on  February  19,  iS'.IS.  She  was  forty  years  old,  and  complained  of  |)i()fus(> 
and  frecjuent  nuMistruation.  <  *n  bel»ru;ny  L'.'id  a  niyoinecidiiiy  was  ilone.  The 
uterus  was  the  size  of  that  of  a  three  and  one-hall'  months"  preunaiicy.  noihilai", 
and  contained  (i\-e  interstitial  myomata.  which  were  I'diioNcd  through  three  in- 
cisions. The  largest  m\'oma  was  5  cm.  in  iliametei'.  ( )n  .Mai'cli  '_'."!.  1S9<I,  the 
uterus  was  only  slightly  enlai'ged  and  fi-eely  mo\ai)le. 

On  Decembei'  11,   1902,  the  i)atient  was  admitted  to  the  Church  Home  and 


566  MYOMATA    OF   THE    UTKKUS. 

Iiiliruiarv.  On  cxaininatioii  we  found  a  nodule,  fully  10  em.  in  diameter,  on 
the  left  side.  The  adhesions  were  broken  up  and  the  uterus  was  removed. 
The  ])atient's  health  five  years  after  the  seeond  o))eration  was  "tolerably  <;ood." 


Immediate  Return  to  the  Hospital  on  Account  of  Adhesions. 
In  Case  6760  a  partially  submucous  myoma.  1.")  cm.  in  diameter,  was  removed 
per  abdomen.  The  patient  made  a  fair  recovery,  but  two  days  after  her  discharge 
returned  to  the  hosi)ital.  The  al)domen  w^as  reopened  and  dense  adhesions 
were  found  between  the  ileum  and  fundus  along  the  myomectomy  hne.  During 
their  liberation  the  ileum  was  torn.  Hysterectomy  was  performed,  but  the 
patient  never  reacted  satisfactorily  and  soon  died.  Examination  of  the  mucosa 
showed  a  marked  endometritis,  and  it  is  quite  probable  that  the  pelvic  infection 
was  due  to  the  wide  opening  up  of  the  uterine  cavity  to  permit  the  enucleation 
of  the  myoma. 

Gyn.  Nos.  6760  and  7036.     Path.  Nos.  3052  and  3315. 

Intestinal  o  I)  s  t  r  u  c  t  i  o  n  foil  o  w  i  n  g  shortly  after 
abdominal     m  y  o  m  e  c  t  o  m  y  . 

Mrs.  L.,  admitted  March  13,  1899.  At  this  time  abdominal  myomectomy 
was  performctl  and  an  interstitial  myoma,  encroaching  upon  the  uterine  cavity 
and  measuring  about  15  cm.  in  diameter,  removed.  The  jmtient  improved  fairly 
i"ai)idly,  and  was  discharged  April  23d.  Two  days  after  leaving  the  hospital 
she  had  a  return  of  the  uterine  hemorrhage.  There  was  constant  oozing,  and 
the  uterus  was  increased  in  size.  At  the  second  operation  it  was  found  that 
the  fundus  was  twice  the  normal  size.  The  appendages  were  bound  down  and 
the  ileum  was  adherent  to  the  fundus  along  the  line  of  the  former  incision.  During 
the  separation  of  these  adhesions  the  ileum  was  ru|)tured.  The  sigmoid  and  rectum 
were  also  densely  adherent  to  the  floor  of  the  pelvis  and  the  j)osterior  surface  of  the 
fundus.  Complete  hysterectomy  was  done,  and  the  rent  in  the  bowel  sutured. 
The  patient  died  on  July  6,  1899. 

Path.  No.  3315.  Histologic  examination  of  the  mucosa  shows  a  marked 
endometritis. 

Pregnancy  Following  Myomectomy. 

Letters  were  sent  to  all  patients  upon  wImhii  an  abdominal  myomectomy  had 
been  performed,  in  order  to  learn  not  only  about  their  subse(iuent  health.  l)ut  also 
whether  they  had  borne  children  after  the  operation.  A  large  number  of  answers 
were  received. 

After  ruling  out  those  that  died  immediately  after  operation,  unmarried 
patients,  widows,  women  oxvv  forty-hve,  and  those  ]iatients  ujion  whom  a  sub- 


ABDChMIXAL    MYUMICCTOMY.  567 

sequent  hysterectomy  was  ])erforine(l,  we  still  have  04  patients  in  whom 
pregnancy  was  possil)le. 

As  we  all  know,  the  menopause  occurs  early  in  some  and  late  in  others,  con- 
sequently we  took  a  middle  ground  in  assuming  forty-five  as  the  arbitrary  age 
at  which  the  menses  should  cease;  otherwise  it  would  have  been  impossible  to 
obtain  an  even  approximate  basis  for  our  calculation.  The  accompanying  table 
shows  that  13  of  the  94  patients  have  been  pregnant — 12  proceeding  to  term,  and 
one  miscarrying.  In  8  of  the  cases  there  has  l)een  only  one  pregnancy,  but  in 
Case  10257  two  chiklren,  and  in  Case  7109  three  chiklren,  were  Ijorn.  In  Case 
2042  the  patient,  who  was  single  at  the  time  of  operation,  is  now  the  mother  of 
four.  The  patient  in  Case  4856  was  single  when  operated  upon.  Over  three 
years  later  she  became  pregnant ;  the  labor  was  long  and  tedious,  and  finally 
Cesarean  section  was  performed,  with  delivery  of  twins.  The  patient  died 
apparently  of  shock.  It  will  be  noted  that  in  this  case  susix'iision  of  tlie  uterus 
had  been  performed. 

\Mien  a  long  suture-line  is  left  in  the  uterus  after  removal  of  a  myoma,  the 
chance  of  omental,  intestinal,  and  other  adhesions  is  great;  on  the  other  hand, 
if  a  suspension  is  done,  the  union  with  the  anterior  abdominal  wall  is  liable  to  be 
very  firm.  In  either  case  there  is  considerable  danger.  After  carefully  weighing 
the  advantages  and  the  disadvantages,  we  have  decided  that  in  those  cases  where 
it  has  been  impossible  to  draw  the  round  or  broad  ligaments  up  over  the  suture- 
line  it  is,  as  a  rule,  wiser  to  suspend  the  uterus  after  the  myomectomy,  provided  the 
suture-Hne  is  in  the  upper  part  of  the  fundus  or  situated  anteriorly.  If  far  down 
posteriorly,  the  uterus  is  dropped  back.  True,  there  are  numerous  disadvantages 
associated  with  the  suspension,  but  when  we  remember  that  in  the  majority  of 
cases  the  i)atients  do  well,  and  further  that,  if  mal{)osition  of  the  pregnant 
uterus  should  by  chance  exist,  we  can  readily  and  i)romi)tly  release  it  with 
httle  danger,  we  shall  not  hesitate  to  choose  the  lesser  of  the  two  dangers,  and 
suspend  the  uterus  in  suitable  cases. 

In  the  accompanying  table  the  size  and  situation  of  the  myomata  are  given. 
Some  of  them  were  small  and  removed  when  the  abdomen  had  been  opened  for 
other  causes.  The  majority  of  the  tumors  were  interstitial.  It  is  particularly 
interesting  to  note  that  in  Case  7159,  in  which  a  subnuicous  myoma  about  8  cm.  in 
diameter  was  present  and  the  uterine  cavity  was  widel>'  ojx'ned.  the  patient 
subse(iuently  had  three  children.  Of  the  13  women  that  bccaiiH"  picgnnnt  sub- 
sequent to  operation,  7  had  previously  l)een  pi-egnaut.  3  sterile,  and  3  were 
single  at  the  time  of  opei'ation. 


568 


MYOMATA    OF   THE    UTKRUS. 
CASES  OF  PREGNAxXCY  AFTi:!!   .M^'()^Il:(•T().MY. 


No. 

Nami.. 

1260 

H. 

1489 

W. 

2042 

K. 

4856 

|H. 

|P. 

Number  of 
Datk  ok  Opkration.     Pregnanciks 

BEFORK    OpER- 


5303 


H. 


30     March,  1892. 


:i') 


.luly.  lSi)2. 
June,  1S93. 


One. 


None. 


28      December,  ISlMi. 


40     May,   1S97. 


Single,  since 
married. 


Siiiiile.  since 
iuarri(Ml. 


Size  of  Myo.mata. 


One  myoma,  2  cm. 
in  (liam.  (suspen- 
sion of  uterus). 

One  interstitial, 
about  (i  cm. 

Sul>j)eritoneal  pe- 
dunculated my- 
oma, 16  cm.  in 
diameter. 

Myoma,  4x8  cm. 
(Uterus  s  u  s - 
l)ended). 


Number  of  Children 
SINX'E  Operatio.n. 


One. 


Two. 


5826 

F. 

34 

7 1  .">9 

,s. 

31 

9243 

N. 

28 

9329 

F. 

38 

1()2.")7 

B. 

23 

10179 

W. 

33 

IIOOO 

S. 

30 

San. 

lo4.-) 

H. 

32 

January.  1S9,S.         Onemis.(?) 


Septemi)er,  1S99. 
November.  1901 . 

.January,  1902. 

Fel)ruary,  190;^. 
Mav,   1903. 


Three. 
None. 

Tliree. 


Single;  since 

married. 
Two. 


January.  H)04.         None. 


Marcli.   1903. 


( )ne. 


Sul)j)eritoneal  mj-- 
oma,  3x5  cm. 
(suspension  of 
uterus,  repair  of 
perineum). 

Two  nodvdes,  sub-  One. 
peritoneal  and  pe- 
dunculated, 15  X 
IS  X  20  cm.;  inter- 
stitial, 2.5  X  3.5  X 
5  cm. 

Partly    submucous.  Three, 
about  8  cm.    Cav- 
ity widely  opened. 

Two   small  intersti-  One. 
tial  myomata  (re- 
lease of  adhesions, 
removal  of     right 
tube  and  ovary). 

Myoma,    4    cm.,    in  One 
right  cornu  (repair 
of  complete    peri- 
neal tear;   su.spen- 
sion  of  uterus). 

Se\'eral  small    inter-  Two 
stitial  myomata. 

(a)  Subnuicous  my-  One. 
oma,    2    cm.;     (b) 
interstitial,    1  cm. 

Three  myomata:  (a)  One. 
2  cm.,  (^)3  cm.,  (c) 
4  cm.    Remo\al  of 
left  liydrosalpinx. 

Interstitial,  5  x  (5  x  One. 
7  cm. 


One. 

Four. 


Died  about  four  years 
later  in  twin  labor. 
Cesarean  section  per- 
formed in  a  distant 
city  after  "a  pro- 
longed and  exhaust- 
ing labor." 

One  miscarriage,  nine 
years  later. 


Present  Condition  of  Patients  after  an  Abdominal  Myomectomy. 
Letters  were  scut  out   to  all  ])ati('nts,  and  from  many  rcplie.s  were  rccoivod. 
Where  no  response  was  forthcominu- il,,.  family  jdiysician  often  kindly  fiu'iiislied 
the  necessary  data.     Finally,  in  a  ^ood  many  cases  the  |)ati('nts  were  visited 
in  their  homes  and  their  present  condition  was  ascertained. 


ABDU.MIXAL    .MYOMECTOMY.  569 

Out  of  the  280  siiocossful  cases,  we  have  accurate  (hita  of  tlie  sul^sefjuent 
history  in  216. 

137  patients  are  well  at  periods  varying  from  a  few  months  to  sixteen  years. 
48  are  in  only  fair  condition.     Some  are  suffering  from  pelvic  trouble,  but 

the  large  majority  from  lesions  remote  from  tlic  pelvis. 
13  reciuired  sul)se(iuent  operation  for  various  troubles. 
18  died  chiefly  from  intercurrent  affections. 

216 

Patients  Remaining  Well  Years  After  an  Abdominal 
M  y  0  m  e  c  t  o  m  y  . — We  have  endeavored  to  be  as  unbiased  as  possible  in  the 
grouping  of  these  cases.  In  a  few  of  the  cases  in  the  following  table  the  patients 
were  not  absolutely  well,  but  said  that  they  were  greatly  benefited,  and  that  their 
general  health  had  been  much  better  since  operation,  or  that  the  operation  had 
been  the  means  of  saving  their  lives. 

Patients  well  10  years  after  oiaeration 3  cases 

"  15       "         "             "            2  " 

"          "  14       "        "            "           1  case 

"  13       "         "             "           2  cases 

II  <<        1 9  u  a  a  9  ii 

"  11  "  "  "  3  " 

"  10  "  "  "  16  " 

"  9  "  "  "  9  " 

"  8  "  "  "  11  " 

"  7  "  "  "  7  " 

"  6  "  "  "  19  " 

"  5  "  "  "  10  " 

tl  U  ^  <<  U  (I  J.^  u 

"       3       "         "             "           18       " 

"       2       "         "             "           6       " 

1  year       "             "            14       " 

"           "     less  than  a  year  after  operation 1  case 

137  cases 

The  reason  that  there  are  so  few  between  the  tenth  and  the  sixteenth  year  is 
because  at  that  time  hysterectomy  was  jx'rformcd  much  more  frecpiently  than 
myomectomy. 

Patients  in  F  a  i  r  ('  o  n  d  i  t  i  o  n  .V  f  1  c  r  a  n  A  b  d  o  m  i  n  a  1 
Myomectomy. — In  this  group  we  haxc  indinh'd  those  i)atients  that  are 
at  present  not  well. 

In  Cases  9024  and  9329  there  isa  persistent  cystitis;  in  Cases  ■)9():).  \)\:{).  11111, 
excessive  menstrual  bleeding,  and  in  (  ases  ()773,  I2()2S.  and  <".  11.  !.,  I'etli.,  from 
thcdata  received,  we  would  not  be  sui'])rised  if  the  uteruscontained  more  myomata. 
Thus  in  only  8  of  48  cases  in  which  the  patieiU  i>  not  well  is  the  trouble  definitely 
attributable  to  the  peK'ic  organs.     ( )!'  the  iciuaining   10  jialieiits,  in  Case  (1070 


570  MVO.MATA    OF   THK    UTERUS. 

there  were  syini^toins  of  some  spinal  lesion,  and  in  Case  69o0  of  asthma  and  em- 
physema. In  Case  7218  there  was  a  renal  lesion,  and  in  Case  7872  a  gastric  ulcer. 
The  rest  of  the  patients  were  either  below  {)ar  or  complained  of  indefinite  symp- 
toms. 


Causes  of  Death  in  Patients  Succumbing  after  Leaving  the  Hospital. 
Eiw'hteen  of  the  21()  jiaticnts  concorniiiii-  whom  we  ha^■o  late  records  are  dead. 

Xo  assigned  cause  (Cases  515,  1455,*  and  7721) 3  cases 

Typlioid  fever,  three  years  later  (Case  9215) 1  case 

Spinal  meningitis,  five  months  after  operation  (Case  4055) 1      " 

Liver  abscess,  several  j^ears  later  (Case  4160) 1      '' 

Pneumonia.    Ovaries  removed  in  another  hospital  several  months  later.    Died  next  year 

of  pneumonia  (Case  7073) 1      " 

Pulmonary  tuberculosis,  four  years  later  suddenly  (Case  1576) 

eleven  years  later  (Case  1821) 

several  years  later  (Case  1916) 

five  years  later  (Case  21S9) I 

ten  years  later  (Case  2500) l 

two  years  later  (Case  6145) J 

Operation  for  release  of  adhesions   (dense  intestinal  adhesions  following  shortly  after 

patient  left  hospital;  ileum  torn  during  operation  (Case  6760) 1  case 

Intussusception.     Well  after  operation,  sudden  intussusception  three  years  later  (Case 

8698) 1      " 

Cesarean  section  for  twins  several  years  after  abdominal  myomectomy  (Case  4856) 1      " 

Obscure  uterine  lesions.     "Died  from  uterine  trouble"  seven  vears  later  (Case  1685).  "i 
Died  apparently  from  some  pelvic  lesion  six  years  later  (Case  4814) / 

18  cases 
*  Died  suddenly  eleven  years  after  operation,  aged  sixty-four. 


CHAPTER  XXX. 
VAGINAL  MYOMECTOMY. 

In  84  of  our  cases  vaginal  myomectomy  was  performed.  Tn  several  other 
cases  a  submucous  myoma  was  enucleated  preparatory  to  an  alxloniiiuil  hyster- 
ectomy.    The  latter  cases  are  describetl  elsewhere. 

Age. — Submucous  myoinata.  in  our  experience,  are  most  coniiiion  during 
the  child-bearing  period,  as  is  indicated  by  the  acconiiJanying  tal)le.  deaUng 
with  the  age  in  SO  of  the  cases: 

Between  20  and  30  years  of  age  8  cases 

"       30  and  40      "      "     "  29      " 

40  and  50      "       "    "  32      " 

"       50  and  55      "      "     "  U      " 

80  cases 

The  youngest  patient  (Case  4382)  was  twenty  years  of  age.  Three  years 
previously  she  had  borne  a  child.  On  admission,  the  uterus  was  found  to  be 
soft  and  thin.  Projecting  from  the  cervical  canal,  and  filling  the  upper  part  of 
the  vagina,  was  a  sloughing  mass,  approximately  6  cm.  in  diameter.  The  ]iatient 
made  a  good  recovery. 

Our  oldest  patient  (Case  8159)  was  fifty-four  years  of  age.  A  submucous 
myoma,  6  cm.  in  diameter,  was  twisted  off,  and  the  ])atient  was  well  six  years 
later. 

Color.  — In  83  cases  we  have  data  as  to  the  color  of  \hc  j)atient.  ( )1"  this 
number,  64  were  white  and  19  colored. 

Symptoms  of  Submucous  Uterine  Myomata. — The  cliief  symptoms  are  Ikmu- 
orrhages  and  its  sequences,  and  those  (hie  to  ])ressui'e. 

Vaginal  Discharge.  — If  we  bear  in  mind  the  \arious  foi-ms  of  sub- 
mucous myomata,  the  various  positions  of  subnuicous  noihiles.  and  the  graihial 
disintegration  of  tlie  myomata,  the  character  of  the  uterine  (Hscharge  will  be 
readily  understood. 

Profuse  menstruation  is,  as  a  I'ule,  the  first  sign  of  a  submucous  nodule;  the 
periods  are  also  jn-olonged.  Menorrhagia,  as  a  rule,  develops  gi-adually,  but.  as 
in  Case  7050,  may  be  co])ious  fi-om  the  first.  In  some  cases  \hr  liemon-hage  iua\- 
assume  alarming  propoi-tions,  as  in  Case  I'J.V.ll.  in  wiiicli  llie  patient  estimated 
a  loss  of  from  thi'ee  to  foui'  pints.  4'lie  How  ina>-  be  ln-iglil  red  in  coloi',  dark,  or 
even  brownish;  when  excessixc.  it  ni.ay  be  clotted,  llie  jiatient  passing  pieces  of 
tissue  resembling  liver. 

In    the   majority   of    the   cases  bleeding   is   the    most    pi-ominent    sym])tom; 

571 


572  MYOMATA    OF   TIIK    ITKRUS. 

ii('\-('rth('l('ss,  ill  a  few,  this  pliciiotiKiioii  is  cntii-cly  wanting'.  In  Cases  10872 
and  11010  no  excessive  flow  was  noted,  and  in  Case  12257  the  last  period  had 
occurred  forty-six  days  before  the  patient's  admission.  In  Case  1489  the  flow- 
was  scant. 

L  e  u  k  ()  r  r  h  c  a  .  In  several  (\ases  (2291,  5687,  9875,  and  11243)  the  dis- 
charge was  l('ui<(irrh('al  in  cliaractei'.  in  some  of  the  cases  being  very  offen.sive. 

P  r  ()  fuse  \'  (•  1  lo  w  i  s  h  Disc  h  a  r  g  e  .  — In  ([uite  a  number  of  cases  the 
flow  was  yellowish  in  color,  thick  or  thin,  and  most  ()tTensi\-e. 

W  a  1  (•  1-  y  1)  i  s  (•  h  a  r  g  e  .  — In  Cases  7383  and  10872  the  discharge  was 
watery  in  character,  and  in  Case  11. ')0  it  was  watery  and  blood-tinged. 

The  h  e  in  o  r  r  h  a  g  e  nsuall\'  indicates  that  a  large  area  of  uterine  mucosa 
has  been  put  on  tension  by  the  submucous  myoma  which  acts  as  a  foreign  body. 
The  offensive  yellowish  oi-  wateiy  discharge  means  that  the  tumor  is  undergoing 
necrosis  and  disintegration.  41ie  odor  in  some  of  these  cases  is  so  oft'ensive  that 
it  takes  hoiu's  to  remove  it  fi'om  the  hands. 

With  the  loss  of  l)lood,  secondary  manifestations  are  noted.  In  Case  10370 
the  patient,  on  account  of  excessive  hemorrhages,  was  compelled  to  remain  in 
bed  ah  the  time.     II(>r  hemogloltin  was  only  30  per  cent. 

In  Case  9()3S  the  loss  of  blood  was  so  great  that  the  ])atient's  vision  was 
l)lurred  and  she  was  dizzy.     Her  hemogloljin  was  reduced  to  21  per  cent. 

In  Case  1 1SS9  the  bleeding  was  severe,  many  clots  being  passed.  Functional 
heart  iiiurmurs  were  heard,  and  the  hemoglobin  had  fallen  to  14  per  cent. 

Loss  of  Wei  g  h  t  .  — When  the  patient  has  had  a  constant  loss  of  blood 
for  years,  there  is  likely  to  be  a  marked  loss  in  weight,  but  when  the  symptoms, 
although  severe,  are  of  short  (Uu-ation,  the  patient  may  still  be  stout,  although 
suffering  from  anemia. 

F  e  V  e  r  and  Chills.  — When  a  sloughing  submucous  myoma  is  present, 
it  is  but  natural  that  ;d)sorption  .should  occasionally  follow,  with  a  subsecjuent 
rise  of  temperature  and  acceleration  of  the  pulse.  We  have  .seen  the  tempera- 
ture reach  100°  F. 

P  r  e  s  s  u  r  e  S  y  m  p  t  o  m  s  .  — Submucous  myomata  must  of  neces.sity  be 
or  become  much  smaller  than  tlie  pelvic  cavity,  in  order  that  exi)ulsi()n  may 
take  i)lace  through  the  vagina.  Occasionally  they  reach  the  size  of  a  "child's 
head,''  as  in  Case  1317.  In  Case  4663  the  myoma  was  18  cm.  long,  but  nuich 
smaller  in  its  other  dimensions,  ^^'hen  pressure  symptoms  are  present,  they  are 
(hie  either  to  large  interstitial  or  siibj)eritoneal  nodules,  or  to  a  large  tumor  mass 
cau.sed  by  a  multiplicity  of  smaller  nodules.  Pressure  symptoms  are  fully  de- 
scril)ed  on  ]).  448. 


Vaginal  Myomectomy. 
It  is  only  necessary  for  us  to  remember  that  we  are  usually  dealing  with  a 
tumor  partially  or  completely  fllling  the  vagina,  and  attached  somewhere  in  the 


V AGIX AL    .M YU.MECTO.M Y . 


573 


uterine  cavity  })y  a  pedicle  varyin<j  from  1  to  3  cm.  in  diameter,  to  at  once  tliink 
of  the  appropriate  sm-^cal  i)rocedure.  The  cases  naturally  fall  into  two  main 
groups. 

1.  Non-infected  .sul)mucous  myomata. 

2.  Infected  and  disinteiirating  subnuicous  myomata. 

Non-infected  Submucous  Myomata. — If  the  vagina  is  large  and  the  myoma  of 
moderate  size,  it  is  often  possi])le  to  place  a  curved  clamp  on  the  pedicle,  and  at 
once  cut  the  myoma  off.     The  pechcle  is  then  \vliii)])ed  over  with  two  or  more 


Fig.  334. — A  Large  Submucous  Myoma. 
Gyn.  No.  2873.  The  patient  had  lo.st  a  great 
deal  of  blood,  and  for  one  week  before  admission 
a  submucous  myoma  had  protruded  from  the 
vulva.  It  measured  11x1.5  cm.  The  patient 
was  very  pale,  cacliectic,  had  a  rapid  and  ex- 
tremely weak  pulse,  and  accelerated  respiration, 
but  an  operation  afforded  the  only  hope.  Va- 
ginal myomectomy  was  done,  the  pedicle  beinK 
-severed  at  the  point  indicated  by  the  dotted 
lines.  The  pulse  soon  rose  to  172,  and  the  tem- 
perature to  102.9°  F.  She  died  within  twelve 
hours  after  the  operation,  apparently  from 
shock. 


Fig.  335. — A  Submucous  Myoma  Greatly  Distending  the 
Vagina. 
Gyn.  No.  2593.  The  uterus  contained  a  single  myoma. 
This  had  become  submucous,  and  finally  pedunculated.  It  had 
been  forced  out  of  the  uterus,  and  markedly  di-stended  the  vagina. 
The  only  way  to  remove  such  a  tumor  satisfactorily  is  to  grasp 
it  firmly  with  me.soforceps  and  remove  successive  wedges  until  the 
ina.ss  is  .so  diminished  in  size  that  it  can  be  delivered.  The 
pedicle  then  can  be  easily  clainpeil,  and  the  tumor  removed. 
The  pedicle  is  then  conl  nillcd  willi  ciitgut  sutures. 


catgut  sutures.  When  the  niyoina  is  still  largtM",  it  may  he  grasped  wilh  iiicso- 
forceps  and  delivered,  a  finger  in  the  rectum  materially  assisting  in  its  expulsion, 
or  it  may  be  po.ssihle  to  deliver  the  tumor  with  o1)stetric  forceps  as  in  Ca.st^  3()()(). 
In  Case  2873  (Fig.  334)  the  large  niyoina  already  protruded  from  the 
vagina. 

When  the  tumor  is  too  large  (Fig.  335)  and  the  vagina  relatively  small,  the 
tumor  may  he  seized  with  two  nie.soforce]:)s  and  bisected  to  the  pediele  ( j-'ig.  33()). 
If  half  of  the  tumor  is  now  cut  off,  the  other  half  will  still  serve  to  steady  the  ped- 


574 


MVO.MATA    OF   THE    UTERUS. 


-Vaginal   Uisectiox    of   a    Sub- 
mucous MVOMA. 
The  myoma  is  firmly  grasped  with  meso- 
forceps  on   either   side,   and    cut    in   two,    as 
indicated    by    the    arrow.     Half    is    then    re- 


iclo  and  prevent  it  from  slipping.  After  halt' 
the  pedicle  has  been  sutured,  the  other  half 
of  the  tumor  is  removetl  and  the  rest  of  the 
pedicle  sutured. 

\\'hen  bisection  is  not  feasible,  a  wedge 
of  the  myoma  may  be  removed  (Fig.  337). 
If  the  tumor  is  still  not  sufficiently  reduced  in 
size,  successive  wedges  are  taken  out  (Fig. 
338)  until  it  can  be  delivered  and  the  pedicle 
controlled  with  catgut. 

In  a  virgin  the  vagina  is  often  so  small 
that  r(Miio\-al  of  the  myoma  by  any  of  the 
methods  suggested  is  not  feasil)le.  In  such 
cases  the  perineum  may  be  incised,  as  was 
done  in  Cases  1610  and  1716.  After  the 
necessary  room  has  been  obtained,  the  my- 
oma is  removed  in  the  usual  wa}'. 

In  Case  3066  the  patient  was  a  widow, 
moved,  and  the  corresponding  half  of  the     agctl   tliirty-five  aud  had   ucvcr   bccu   prcg- 

pedicle    controlled    with    catgut.     The   other  "  .  x^ii      i  •    i 

half  is  then  removed,  and  its  vessels  are  con-  UaUt.         1  hc     VaglUa    WaS     hllcd     With      a     Sul)- 

trolled,  the  sutures  already  introduced  mean-  j^^^.^^^^      mvoma,      6    X     11     X     11      CUl.        The 
while  serving  as  a  tractor. 

perineum     on    the    right    side    was    incisetl 
down  to  the  rectum  and  the  tumor  delivered  with  obstetric  forceps. 

When  the  myoma  has  not  been  completely  expelled  into  the  vagina  or  lies 
partly  in  the  cervical  canal,  it  may  be  necessary 
to  s))lit  the  cervical  lij)s  both  anteriorly  and  pos- 
teriorly or  laterally  until  the  pedicle  is  reached. 
The  remainder  of  the  o])eration  is  then  relatively 
easy.  This  method  was  employed  in  Cases  5242 
and  5296. 

Sometimes,  notwithstanding  the  care  used,  the 
l)edicl(>  is  so  friable  that  the  stitches  will  not  hold 
or  it  may  slip  through  the  artery  forcej)s.  It  im- 
mediately retracts,  and  its  subse(iuent  control  is 
impossible.  In  such  cases,  as  a  I'ule,  it  suffices  to 
pack  the  uterine  cavity  tightly  with  iodoform  gauze, 
which  is  remo\'ed  after  twenty-four  oi'  forty-eight 
hours. 

Occasional!}'  the  pedicle  of  the  iiiyoma  is  at- 
tached to  the  cei-\-ical  lips  instead  of  projecting 
through  the  cervical  canal.  In  such  a  case  a 
wedge-.shaped  incision  is  made  in  the  cervix,  the 
myoma  withdrawn  and  the  resultant  space  closed  as  indicated  in  Figs.  339  and  340. 


Fic;.  .337 — ^h^THOI>  ok  Rkmoving  a 
\khv  Lauge  Submucous  Myoma 
When  the  submucous  myoma 
greatly  distends  the  vagina,  as  in 
tliis  case,  a  wedge  may  be  removed, 
as  indicated  by  the  dotted  lines.  If 
the  remaining  portion  is  still  too 
large,  succe.ssive  segments  are  cut 
away,  as  indicated  in  Fig.  33S. 


VAGIXAL    MYOMKCTOMV. 


575 


Fig.  338. — Mkthod  of  Deliver- 
ing A  Very  Large  Scbmu- 
COU.S  Myoma. 


Years  ago  it  was  the  custom  to  remove  suhmucous  myomata  ])y  means  of  an 
ecraseur,  and  then  it  was  very  important  for  the 
operator  to  determine  with  absolute  certainty  whether 
partial  inversion  of  the  uterus  was  present.  Several 
3' ears  ago  I  saw  a  surgeon  remove  a  su})nuu'()us  my- 
oma with  the  wire.  To  his  great  astonishment,  after 
removal  of  the  tumor,  he  found,  wdiere  the  pedicle 
should  have  been,  a  hole  fully  2.5  cm.  in  diameter, 
communicating  directly  with  the  abdominal  cavity. 
The  weight  of  the  su1)nmc()us  nodule,  together  with 
the  usual  expulsive  movenient.  had  occasioned  pai'- 
tial  inversion  of  the  uterus.  He  had  removed  fully 
half  of  the  fundus.  Fortunately,  no  intestines  had 
dropped  into  the  cup4ike  depression,  otherwise  these 
also  would  have  been  severed  by  the  ecraseur. 

With  the  abandonment  of  the  wire  and  the  cm-  "^^^  *"'""'"  '^  altogether  too 

large  to  be  removed  intact   from 

ployment  of  the  simple  method  of  operating  imdcr     the  vagina,    it  is  grasped  with 

•    1,  1  Ti.-  Ill  11       1  forceps,  and  successive  wedges  are 

Sight,  such  a  complication  could  hardly  be  encoun-     .amoved  in  the  order  indicated. 

tered.  ^'^  *^'^  ^^y  ^^^  pedicle  is  finally 

clearly     exposed     and     controlled 

In  four  of  our  cases  (1610,  1^16,2873,  and  7133)      with  catgut, 
slight  inversion  of  the  uterus  was  noted  at  operation. 

In  some  instances,  as  in  (Aise  4967,  in  which  a  submucous  myoma  projected 

from  a  large  multinodular  uterus,  it  may 
be  possible  to  do  a  vaginal  myomectomy 
and  then  immediate  removal  of  the 
uterus  from  above. 

Removal  of  Infected  and  Disintegrat- 
ing Submucous  Myomata. — A  reference 
to  p.  572  will  show  how  foul  a  condition 
of  the  vagina  may  be  caused  by  infected 
and  disintegrating  myomata,  and  it  will 
l)e  readily  seen  that  no  nniount  of  j)re- 
])arat()rv  cleansing  will  gi\'e  the  ojx'rator 
a  clean  field  for  operation.  He  must  ac- 
cordingly opci'ntc  ill  such  ;i  way  thai  the 
vagina  or  cciAix  is  in  no  way  injured, 
otherwise  a  serious  general  infection  may 
result.  When  1  heiiiyomaisfirm,  it  may  be 
bisected  and  iciiioxed,  or  its  size  may  he 
materially  reduced  by  lirst  taking  away 
one  or  more  wedges  of  tissue.  Inder  no 
(■ir(MiMistanees,  how-e\-er,  should  the  peri- 
lieiilii   be  incised  or  the  celA'ix  split. 


Fig.  339. — Suture  of  the  Cervix  After  Rkmovai. 
OF  A  Submucous  Myo.ma. 
The  pedicle  of  a  submucous  myoma  is  usually 
attached  high  up  in  the  cervical  canal  or  in  the  uter- 
ine cavity,  but  occasionally  sijrings  from  the  cervix. 
In  such  cases  it  is  removed  as  a  wedge  from  the  cer- 
vix, and  the  resultant  space  closed  with  formalin  and 
plain  catgut.  If  the  incision  has  extended  high  iij) 
laterally,  care  must  he  exercised  not  to  pierce  the 
uterine  arterv  with  tlie  needle. 


•6 


]MYOMATA    OF   THK    ITKRUS. 


lii  many  cases  a  degenerated  myoma  resemhles  a  toiiiih  piece  of  beef  that 
has  lain  in  water  for  a  longtime.  Such  tissue  is  very  soft  and  boggy.  It  cannot, 
however,  be  easily  torn,  but  can  l)e  readily  cut  away  with  the  scissors.  When 
the  tissue  is  very  friable,  it  can  be  brought  away  piecemeal  with  placental  forceps. 
Sometimes  it  is  possible  to  control  the  stiunj)  with  catgut,  l)ut  when  this  will  not 
hold  and  when  bleeding  occui's.  the  thermocautery  may  be  employed.     After 

removal  of  these  myomata  it  is 
well  to  give  a  vaginal  douche  of 
bichlorid  solution  and  to  j^ack 
lightly  with  iodoform  gauze. 


y 


^  r 


Complications  Occurring  During 
Vaginal  Myomectomy. 

1.  rncoiitrollable         hiiMMling 
from  the  pedicle. 

2.  Rupture  of  the  uterus. 
Hemorrhage. — In  Case  6604  the 

patient  was  thirty-four  years  of  age 
and  single.  A  wedge  was  removed 
fiom  the  submucous  myoma  which 
filled  the  vagina.  Suddenly,  the 
tumor  tore  away  from  its  pedicle 
and  was  delivered.  The  pedicle 
was  far  uj)  in  th(>  cervical  canal. 
As  there  was  steady  l)leeding  from 
the  uterus  and  as  it  was  impossible 
to  draw  the  cervix  down  so  that  the 
bleeding  area  could  be  exposed,  the 
uterine  cavity  was  tightly  packed 
with  gauze,  but  the  bleeding  still 
continued.  The  abdomen  was  then  opene<l,  and  l)oth  of  the  uterine  arteries  were 
tied.  On  the  right  side  tliis  ])ro(M'dui'e  was  didicult  on  account  of  dense  adhe- 
sions, which  bound  the  tube  and  (A'ary  and  the  uterus  to  the  pelvic  floor.  The 
patient  eight  years  later  wrote  that  .^he  was  in  good  health. 

This  case  is  anothei-  st  riking  example  of  the  necessity  of  always  being  prepared 
to  do  an  abdominal  operation  whenever  any  important  vaginal  work  is  under- 
taken. We  always  make  it  a  point  to  have  the  abdomen  cleancnl  in  such  cases 
s(j  that  no  delay  will  be  necessary  if  its  exploration  should  .suddenly  be  found 
imperative. 

Rupture  of  the  Uterus. — In  Case  \)]'A7  the  woman  was  forty-eight  years  of 
age.  The  outlet  was  small,  and  a  liai'd  oval  mass,  (i  x  10  cm.,  hlled  the  vagina. 
The  cervical  canal  was  fully  1  cm.  in  diameter,  and  the  pedicle  could  be  felt 


Fig.  .340. — Appearance  of  the  Cervix  After  Removai, 
OF  A  Submucous  Myoma  that  Had  Been  Attached 
TO  the   Vagixal   Portion  ok  the  Cervix. 


VAGINAL    MYOMECTUMY.  577 

extending  up  into  the  uterine  cavity.  The  tumor  was  partially  bisected  and 
twisted  off.  A  sound  passed  up  into  the  cavity  at  the  ]X)int  of  the  pedicle  went 
directly  into  the  abdominal  cavity.  A  small  gauze  di'aiti  was  carried  into  the 
uterus,  but  nothing  further  was  done.  The  patient,  in  wi'iting  five  years  later, 
stated  that  she  was  well. 

In  such  a  case  it  would,  of  course,  be  much  wiser  to  clamp  and  cut  the  pedicle 
instead  of  twisting  it  off. 

In  this  connection  it  may  be  interesting  to  mention  Case  12323.  The  patient 
was  thirty-two  years  of  age  and  com])lained  of  amenorrhea.  Although  th(^  ut- 
most care  was  used  in  curettage,  the  instnunent  suddenly  ])assed  into  the  abdom- 
inal cavity.  Anterior  vaginal  section  was  done,  and  a  small  perforation  found 
just  on  the  edge  of  the  subperitoneal  myoma,  not  over  3  nun.  in  diameter.  The 
minute  nodule  was  removed,  and  the  rupture  closed.  The  patient  suff'ercd  no 
ill  effects  from  the  mishap. 

Vaginal  Myomectomy  on  a  Patient  Almost  Moribund.  Recovery. — The  follow- 
ing case  demonstrates  that  even  when  the  patient  has  ])n)found  toxemia  as  a 
result  of  a  sloughing  gangrenous  myoma,  she  may  rally  if  the  tumor  is  removed. 
Dr.  Gerry  R.  Holden,  of  Jacksonville,  Fla.,  who  was  resident  gjmecologist  at  the 
time,  felt  almost  certain  that  the  patient  would  succumb,  but  took  the  only 
chance.  The  speedy  recovery  was  little  short  of  marvelous,  and  the  patient 
wrote,  two  years  later,  that  her  health  was  better  than  ever. 

Gyn.  No.  11889.     Path.  No.  8297. 

L.  V.  G.,  colored,  aged  thirty-two,  admitted  February  13,  1905.  She  had  had 
one  child,  and  no  miscarriages.  During  the  last  year  she  had  experienced  a 
great  deal  of  pelvic  pain  at  the  menstrual  period,  and  had  had  to  remain  in  bed 
frequently  during  the  flow,  which  had  been  excessive.  For  the  last  three  weeks 
she  had  been  in  Ijed.  Ten  days  before  her  ])h3'sician  packed  the  uterus  with 
iodoform  gauze,  and  gave  ergot  to  control  the  hemorrhage.  The  patient  be- 
came very  weak  and  anemic  from  the  repeated  hemorrhages,  and  had  a  high 
fever  and  one  severe  chill. 

On  admission  she  seemed  to  be  in  an  almost  moribund  condition.  She  was 
markedly  delirious,  suffered  great  ])ain,  and  had  a  rectal  temperature  of  104.2°  F. 
The  pulse  was  weak,  irregulai',  140  to  the  minute,  and  could  not  be  felt  in  the 
right  wrist.  The  respirations  were  40,  and  a  loud  systolic  murmur  could  be 
heard  at  the  apex  and  was  transmitted  to  the  midaxillary  line.  II(>r  hemoglobin 
was  14  per  cent.  She  was  stimulated  at  night,  and  in  the  morning  the  tempera- 
ture was  somewhat  lower  and  the  pulse  better.  ( )n  alidDininal  examination  it 
was  found  thai  a  I'oun ded  tumor  fille(l  ihc  |)el\is  and  extended  as  fai'  as  ilir  um- 
bilicus. Th(!  abdomen  was  very  sensiti\-e.  ( >n  \aginal  examinalion  llie  cervix 
was  found  to  l)e  dilated,  the  external  os  Ix'ing  1  cm.  in  diameter.  I'l'ojecting 
from  the  cervix  was  a  nasty,  grayish-while,  neci'olic,  submucous  myoma.  The 
37 


578  MYOMATA    OF   THE    UTERUS. 

hand  introduced  within  the  cervix  palpated  a  mj'onia  which  reached  high  into 
the  abdomen. 

Operation  under  nitrous  oxid  anesthesia.  The  cervix  was  well  exposed. 
The  tumor  was  seized  with  a  heavy  mesoforceps  and  an  effort  made  to  take  it  out 
piecemeal.  Over  one-quarter  of  the  tumor  was  gotten  away  in  this  manner. 
The  tissue  was  foul-smelling  and  necrotic.  An  iodoform  gauze  pack  was  in- 
troduced into  the  uterus.  The  prognosis  was  exceedingly  grave.  Recovery  was 
slow,  owing  to  thrombosis  of  the  right  femoral  vein  and  also  to  nephritis.  On  her 
discharge,  one  month  and  twenty-five  days  after  o])eration,  her  hemoglobin  was 
60  per  cent.,  her  general  condition  good.     She  refused  further  operation. 

Path.  Xo.  8297.  The  largest  piece  of  tissue  was  2x6x9  cm.  Even  after  the 
specimen  had  been  in  alcohol  for  a  year  and  a  half  the  odor  was  most  disgusting, 
and  sections  showed  that  the  tissue  was  necrotic.  The  surface  was  covered  with 
polymorphonuclear  leukocytes,  and  in  the  blood-vessels  were  what  appeared  to 
be  myriads  of  micro-organisms. 

January  9,  1907:  We  are  just  in  receipt  of  a  letter  from  the  patient  in  which 
she  says :  ''My  health  is  better  than  ever.  I  am  healthier  than  ever  and  stouter." 
Of  course,  in  this  case  a  large  portion  of  the  submucous  myoma  is  still  in  the 
uterus. 

Other  Operations. — In  the  majority  of  our  cases  the  vaginal  myomectomy 
was  the  only  oi)eration  performed.  In  Case  6855,  however,  after  removal  of 
a  submucous  myoma,  3.5  x  4  x  8  cm.,  a  vaginal  cyst,  2x3  cm.,  was  excised  from 
the  left  side  and  a  tubo-ovarian  abscess  containing  about  80  c.c.  of  non-fetid  pus 
evacuated.  The  pus  from  the  pelvic  abscess  might  very  readily  have  infected 
the  wound  from  which  the  vaginal  cyst  had  been  removed. 

In  Case  10314  a  submucous  adenomyoma,  approximately  7x7x11  cm., 
was  removed  from  a  patient  having  a  double  vagina  and  a  double  cervix.  The 
vaginal  septum  was  removed.  This  case  is  repoited  at  length  in  "Adenomyoma 
of  the  Uterus,"  p.  161. 


Complications  Following  Vaginal  Operations  for  Uterine  Myomata. 

1.  Elevation  of  temperature  and  pulse. 

2.  Phlebitis. 

3.  Erysipelas. 

4.  Delirium. 

Elevation  of  Temperature  and  Pulse. — In  57  of  our  successful  vaginal  myo- 
mectomies we  have  accurate  data  as  to  the  postoperative  temperature.  From 
the  accompanying  table  it  will  be  seen  that  21  of  the  patients  had  a  tempera- 
ture of  101°  F.  or  over,  after  the  operation.  It  will  be  further  noted  that  in 
nearly  all  these  cases  the  myoma  removed  was  disintegrating  and  naturally, 
therefore,  was  infected. 


VAGINAL    MYOMECTOMY. 


579 


The  highest  temperature  (105.5°)  was  noted  in  Case  4382.  The  patient  had 
suffered  from  fever  and  chills  ])efore  the  operation. 

The  maximum  temperature  was  usually  present  on  the  second  or  thii-(l  day. 
With  the  rise  in  temi)erature  there  was  naturally  a  coincident  rise  in  the  pulse- 
rate. 

CASES  OF  VAGINAL  MYOMECTOMY  WITH  A  POSTOPERATIVE  TExMPERATURE  OF 

OVER  101°  F. 


Case  No. 

Highest  Temperature. 

Day  .\fter  Operation. 

Character  of 

.Myoma. 

301 

101.6° 

Third. 

Blackish  red. 

1317 

104° 

Third. 

Strangidated. 

1489 

102.2° 

Third. 

1551 

102.2° 
(Restless,  delirious.) 

Third. 

Sloughing. 

1610 

102.6° 

Second. 

Smooth. 

1716 

102° 

Second. 

4382 

105.5° 

Chills  and  fever  before  operation: 

Temp,  reached  normal  29th  day. 

First. 

Sloughing. 

4794 

101.9° 

First. 

Sloughing. 

5296 

102.6° 

First. 

Sloughing. 

5496 

103.6° 

Third. 

Sloughing. 

5622 

101.4°. 

Sixteenth. 

Smooth. 

587  U 

105° 

Fifth. 

Smooth. 

6441 

101.2° 

Second. 

Necrotic. 

6604 

101.2° 

Second. 

6833 

102° 

Fifth. 

Sloughing. 

7050 

102° 

First. 

Sloughing. 

10376 

101.8° 

Second. 

Sloughing. 

10618 

105° 

Second. 

Sloughing. 

10635 

102° 

Second . 

Smooth. 

12257 

102.2° 

Third. 

Sloughing. 

13014 

101.4° 

First. 

Sloughing. 

Phlebitis. — In  Case  10314,  after  removal  of  a  submucous  adenomyoma,  the 
patient  developed  a  phlebitis  in  the  left  leg  on  the  twenty-first  day.  Her  highest 
temperature  was  100°  F.  Tt  is  interesting  to  note  that  in  none  of  the  21  cases 
in  which  the  postoperative  temperature  exceeded  101°  F.,  did  ])hlebitis  develop. 

In  Case  11889  the  patient  entered  the  hospital  with  a  large  sloughing  sul)- 
mucous  myoma.  Her  hemogio])in  was  only  14  per  cent.  Despite  the  fact  that 
she  was  almost  moribund,  vaginal  myomectomy  was  undertaken  and  she  made 
a  good  recovery.  The  case  is  re])ort(Hl  in  detail  on  \).  577.  I  )uring  convalescence 
she  had  thrombosis  of  the  i-ight  femoral  vein,  and  also  of  the  superlicial  veins  of 
the  neck. 

Erysipelas. — In  Case  12079  the  patient,  forty-six  years  of  age.  had  a  sloughing 
submucous  myoma.  \'aginal  myomectomy  was  jierformed,  and  the  uterus  was 
dilated  and  curetted.  ( )n  the  eighth  da>'  foll(t\\ing  the  second  anesthesia  there 
was  a  sudden  rise  of  tempei'ature,  and  erysipelas  develoiieij  ;ii  the  jxiiiit  at  which 
a  subcutaneous  infusion  had  been  given. 

The  pathologic  report  (8655)  showed  that  the  surface  of  the  myoma  was 
composed  of  typical  gramilation  tissue,  and  lh;it  many  of  the  blood-ve.ssels  were 


580  MYOMATA    OF   THE    UTERUS. 

filled  with  organisms.  It  is  possible  that  the  infection  canic  from  the  uterine 
tumor.  The  patient,  however,  had  had  an  attack  of  erysipelas  four  years  before 
her  operation,  at  a  time  when  no  uterine  tumor  had  been  detected. 

Delirium. — In  Case  1551  the  patient,  aged  forty-seven,  white,  gave  a  history 
of  a  vaginal  myomectomy  foui-  years  before  admission.  On  examination  a  myo- 
matous uterus  was  found  filling  the  i)elvis  and  extending  almost  to  the  umbilicus. 
A  very  offensive  gangrenous  mass  filled  the  vagina.  The  ))atient  was  noisy, 
restless,  and  had  a  ra])id  jnilse  on  admission.  As  nuich  as  p()ssil)]e  of  the  slough- 
ing myoma  was  removed,  and  an  iodoform  pack  introduced.  After  operation 
the  patient  was  still  restless,  delirious,  and  noisy  at  times.  The  maxinmm  tem- 
perature was  102.2°  F.,  on  the  third  day.  Twelve  days  later  more  of  the  sub- 
mucous myoma  had  been  forced  into  the  vagina,  and  this  was  twisted  off.  With 
the  removal  of  the  sul)nuicous  nodule  the  jwtient  si)eedily  I'ecovered,  although 
the  uterus  contained  other  myomata.  The  restlessness,  delirium,  and  tempera- 
ture were  undoubtedly  due  to  .'^e))tic  absorption  from  the  sloughing  submucous 
mvoma. 


Immediate  Death  Following  Vaginal  Myomectomy. 

In  84  cases  submucous  myomata  were  removed  through  the  vagina;  79 
patients  recovered  and  5  died. 

On  referring  to  the  history  of  Case  1441  it  will  be  seen  that  the  operation  was 
a  simple  one,  and  that,  under  ordinary  circumstances,  we  should  have  expected 
recovery.  The  woman  died  in  a  state  of  profound  asthenia  on  the  thirteenth 
day.  We  are  not  clear  as  to  the  cause  of  death,  but  infection  may  possiljly  have 
been  spread  from  a  primary  focus  in  the  myoma. 

In  Case  2873  the  woman  was  in  a  desperate  condition  on  admission,  not  only 
on  account  of  the  great  loss  of  blood,  but  also  from  septic  absorption.  Operative 
interference  offered  the  only  possible  chance  of  relief.  Although  the  operation 
itself  was  a  simple  one,  she  died  in  profound  shock  twelve  liours  later. 

In  Case  3426  the  condition  was  a  most  complicated  one.  Not  only  was  there 
infection  in  the  vagina,  but  an  ovarian  abscess  was  also  present.  It  is  little 
wonder  that  the  patient  died  of  general  ])entonitis.  With  our  present  knowledge 
of  these  cases  we  never  do  an  exploratory  abdominal  operation  when  a  sloughing 
siibnmcous  myoma  is  present.  The  necrotic  submucous  growth  is  removed 
through  the  vagina.  After  several  weeks,  when  the  vaginal  discharge  has  ceased 
and  when  the  dangers  of  infection  are  greatly  reduced,  an  abdominal  hysterec- 
tomy is  done  if  necessary.  In  the  case  under  discussion  any  o])erative  measure 
would  have  been  accompanied  ])y  the  greatest  danger. 

In  Case  3508  death  occurred  six  weeks  after  operation.  The  })atient,  on 
admission,  was  nuich  mn  down,  and  recently  had  been  vomiting.  The  operation 
was  not  responsible  for  her  death,  but  failed  to  tide  her  over,  her  vitality  having 
become  too  low. 


VAGIXAL   MYOMECTOMY.  581 

The  history  of  Case  6185  reveals  the  desperate  condition  of  the  patient  on 
admission.  She  had  a  moderate  fever,  a  rapid  pulse,  and  a  foul,  slougliing, 
brownish-green,  myomatous  mass  projecting  down  beneath  the  thighs.  There 
is  little  wonder  that  she  succumbed  on  the  fourth  day. 

In  this  case  it  might  have  been  wiser  to  leave  the  clamps  attached  to  the  pedi- 
cle instead  of  attempting  to  suture  the  stump. 

Gyn.  No.  1441. 

"\^  a  g  i  n  a  1    m  y  0  m  e  c  t  0  m  y  .     Death. 

S.  L.,  white,  married  thirty-two  years.  Admitted  June  20;  died  July  3, 
1892.  Operation,  June  21,  1892;  removal  of  a  suljmucous  myoma  by  mor- 
cellation.  The  uterus  was  packed  ^\ith  gauze  to  control  hemorrhage.  After 
the  operation  the  patient  had  a  considerable  quantity  of  seropurulent  discharge, 
interspersed  \\itli  a  few  hemorrhages  of  small  amount.  Toward  the  end  there 
were  vomiting  and  periods  of  extreme  restlessness,  usually  followed  by  uncon- 
sciousness and  feebleness  of  the  pulse  and  respiration.  The  patient  died  in  a 
state  of  profound  asthenia  on  the  thirteenth  da3\  Her  temperature  reached 
102.8°  F.  on  the  third  day,  but  was  below  99.5°  F.  after  the  ninth  day. 

Gyn.  No.  2873. 
Vaginal     myomectomy.     Death. 
C.  D.,  aged  forty-nine,  white,  married.     Admitted  June  23;  died  June  23, 

1894.  The  patient,  on  admission,  gave  a  history  of  having  had  a  submucous 
myoma  removed  a  week  before  admission.  She  had  lost  a  great  deal  of  l^lood 
recently,  and  was  very  cachectic  and  weak.  On  admission  she  was  found  to  be 
poorly  nourished  and  very  j)ale;  she  had  a  rapid  and  extremely  weak  pulse  and 
a  rapid  respiration.  A  large  myomatous  tumor,  11  x  15  cm.,  projected  from  the 
vulva.  It  was  attached  by  a  pedicle  4x5  cm.,  and  the  uterus  was  partly  in- 
verted. Vaginal  myomectomy  was  done,  and  a  second  nodule,  2x3  cm.,  was 
removed  from  \nthin  the  cervix.  Thirty  catgut  ligatures  were  rccjuircd  to  con- 
trol the  oozing.  The  cavity  of  the  uterus  was  packed  with  gauz(\  The  patient 's 
pulse  rapidly  rose  to  172,  her  temperature  to  102.9°  F.,  and  she  died  within 
twelve  hours  after  operation  in  a  ('()n(Hti()n  of  markc^d  shock. 

Gyn.  No.  3426. 
Vaginal     m  y  0  m  e  c  t  o  m  y    f  o  r    a    si  o  u  g  h  i  n  g     s  u  b  m  u  c  o  u  s 
myoma.     Death    from    general     p  c  i-  i  t  o  n  i  t  i  s  . 

A.  S.,  single,  aged  forty-five,  colored.     Ailmil  tctl   April   7;    died   April    17. 

1895.  For  the  ])ast  year  the  menses  have  been  less  regular  and  scant.  Her  lasi 
])eriod  comnuMiced  four  weeks  ago,  and  the  (low  since  then  has  been  contimious. 
Twelve  years  ago  the  patient  noticed  a  small  lump  in  tlu^  right  side.  This  has 
grown  gradually  larger.  Four  weeks  ago  she  began  to  ha\'e  severe  pain  accom- 
panying the  coi)ious  discharge. 


582  MYOMATA    OF   THK    UTERUS. 

Operation,  April  11,  1895,  exploratory  celiotoiiiy;  inyoiiiectoniy  through  the 
vagina.  AVhen  the  abdomen  was  opened,  a  large  myomatous  uterus  was  found 
densely  atlherent  to  the  pelvic  floor.  The  abdomen  was  at  once  closed.  The 
cervix  was  distended  by  a  sloughing  submucous  myoma,  which  had  been  partly 
expelled  thi'ough  the  vagina  and  was  removed  as  far  as  |)ossible  with  the  ecraseur 
and  curet;   the  uterus  was  then  i)acked. 

The  ))atient  develo])ed  signs  of  general  peritonitis — constant  abdominal  pain, 
nausea,  and  xoniiting.  The  temperature  gradually  rose  to  103.7°  F.  on  the  sixth 
day,  falling  suddenly  to  normal  just  before  her  death  on  the  sevcMith  day. 

Aut.  No.  ()5o.  Anatomic  (Hagnosis:  Sloughing  uterine  myoma,  infection 
of  the  vagina,  cavity  of  the  uterus  and  Fallopian  tubes.  The  right  ovary  was  the 
seat  of  an  ovarian  abscess,  and  there  was  wide-spread  fil)rinopurulent  i)ei'itonitis. 
Both  ureters  were  dilated.  At  autopsy  cultures  yielded  Streptococcus  from 
the  peritoneal  cavity  and  also  from  the  vagina. 

Gyn.  No.  3508. 

A'  a  g  i  n  a  1  m  y  o  m  e  c  t  o  m  }-  f  o  r  a  sloughing  s  u  b  m  u  c  0  u  s 
m  y  o  m  a  .     Death      six     weeks     1  a  t  e  r  . 

L.  M.,  aged  thirty-five,  colored,  married.  Admitted  ^lay  13;  died  July 
30,  1895.  For  three  weeks  prior  to  admission  the  patient  has  had  an  offensive 
bloody  discharge  containing  shreds  of  broken-down  tissue.  Eighteen  months 
ago  she  first  noticed  an  abdominal  tumor.  It  has  been  gradually  getting  larger, 
and  for  the  two  months  there  has  been  some  abdominal  })ain.  Recently  the 
jiatient  has  been  vomiting  considerably. 

Oi)eration,  May  15,  1895.  A  sloughing  sulmmcous  myoma  was  removed, 
and  the  uterus  dilated,  curetted,  and  washed  out.  The  patient's  highest  tem- 
perature was  103.2°  F.,  on  the  third  day.  She  gradually  grew  weaker  and  died 
six  weeks  after  operation. 

Gyn.  No.  6185.     Path.  No.  2441. 

Removal  of  a  G  a  n  g  r  e  n  o  us  Sub  m  u  c  o  u  s  ^l  y  o  m  a  (Fig. 
341).     Death. 

A.  W.,  aged  fifty-four,  colored,  married.  Admitted  June  21 ;  died  June  25, 
1898.  The  patient  was  admitted  as  an  emergency  case.  Between  the  thighs 
was  a  large  ovoid  tumor,  dark  brownish-green  in  color.  This  was  covered  with 
a  bloody,  foul-smelling  discharge,  and  measured  8  x  15  cm.  It  projected  from 
the  cervix,  the  jx-diclc  being  2.5  cm.  in  diameter. 

Operation,  June  22,  1898.  It  was  impossijjle  to  clean  the  vagina  thoroughly. 
The  pedicle  of  the  tumor  was  clampetl,  and  the  sloughing  growth  removed. 
Several  sutures  were  passed  through  the  cervix  to  stop  the  oozing,  as  it  was 
impos.sible  to  satisfactorily  control  the  pedicle.  A  smaller  myoma  was  also 
grasped  with  mesoforeeps  and  twisted  off.  The  uterine  cavity  was  then  tightly 
packed  with  iodoform  gauze.     The  uterus  itself  after  removal  of  the  tumor 


VAGINAL    MYOMECTOMY. 


583 


Mt 


W^: 


'^^^ 


was  about  11  cm.  in  diameter.  The  patient  did  not  do  well  after  operation. 
Her  temperature  on  admission  was  99°  F. ;  after  tlie  operation  it  rose  to  101.8°  F. ; 
on  the  second  day  it  dr()i)ped  to  99.5°  F.;  on  the  third  day  it  rose  to  103°  F., 
and  on  the  fourth  day  it  reached  106.2°  F.  shortly  before  death.  The  pulse  on 
her  admission  was  115;  shortly  before  death  it  rose  to  158. 

Path.  No.  2441.  The  specimen  consists  of  a  pear-shaped  submucous  nodule, 
approximately  7  x  12  cm.  Its  surface  is  slightly  roughened,  and  on  section  it 
presents  the  typical  myomatous  appearance.  Sections  from  the  surface  of  the 
tumor  show  no  trace  of  mucosa.  The  surface  is  covered  with  myriads  of  poly- 
morphonuclear leukocytes  and  necrotic  tissue.  Beneath  this  is  a  very  vascular 
zone,  composed  of  large 
and  small  blood-vessels 
(Fig.  341).  So  abundant 
are  the  vessels  that  in 
places  they  occupy  half 
the  field.  Some  of  these 
vessels  contain  organizing 
thrombi.  The  surround- 
ing stroma  shows  a  con- 
siderable amount  of  hem- 
orrhage, or  is  infiltrated 
with  many  polymorpho- 
nuclear leukocytes.  The 
tumor  consists  of  non- 
striped  muscle-fibers  cut 
in  various  directions,  and 
presenting  the  characteris- 
tic myomatous  appear- 
ance. In  some  places  there 
is  hyaline  degeneration, 
with  a  gradual  melting 
away  of  the  myoma,  noth- 
ing but  a  dchcate  reticulum 
being  left.     We  are  dealing 

with  an  ordinary  submucous  myoma,  tlic  surfac(>  of  wliidi  ha 
and  disintegrated.  It  is  exceptional  to  find  so  many  Mood-vi 
They  readily  account  for  the  free  hemorrhage  noted. 

Aut.  No.  1112.  Anatomic  diagnosis.  (Jangrcnous  sui)inu('ous  myoma; 
acute  vegetative  aortic  and  milral  endocarditis;  septic  infarction  of  the  left  hmg: 
acute  locahzed  pleurisy;  old  pleui'itic  adliesions;  ehi^Miic  interstitial  splenitis; 
subacute  glomerular  nephritis;  miliary  abscess  in  the  left  kidney.  Chronic 
adhesive  pelvic  peritonitis. 

In  this  case  the  weakened  condition  of  the  patient  was  cei-tainly  caused  by 


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341. — A  Vp:Ry  Vascular  Si.ou(;hing  Submucous  Myoma. 
(X  lOOdiam.) 
Gyn.  No.  6185.  Path.  No.  2441.  The  .surface  of  the  myoma 
consisted  of  necrotic  tissue  covered  and  infiltrated  witli  ijoiynior- 
phonuclear  leultoeytes.  Beneath  this  was  an  exceedingly  vascular 
zone.  As  seen  from  the  ))icture,  nearly  half  the  field  is  made  up  of 
large  and  small  markedly  dilated  veins.  The  muscular  elements  have 
to  a  great  extent  disappeared,  and  the  tissue  is  infiltrated  with  small 
niund  cells  and  fragmented  niiiU'l.  There  has  also  been  much  hemor- 
rhage into  the  tissue. 


hecoiiie  necrotic 
els  in  ;i  niN'om.a. 


584  MYOMATA    OF   THE    UTERUS. 

the  profuse  liciiiorrhages;  the  acute  endocarditis  and  the  niiUary  abscesses  can 
Uke\A'ise  easily  be  accounted  for  by  infection  from  the  foul  sloughing  and  infected 
myoma.  The  death  can  certainly  be  attributed  to  the  submucous  myoma  in 
this  case. 


A  Fatal  Case  in  which  Vaginal  Myomectomy  was  Impossible. 
Gyn.  No.  8804. 

From  the  following  history  it  is  seen  that  the  patient  was  suffering  from  a 
most  profound  anemia  and  from  absorption  from  a  large  sloughing  myoma. 
Vaginal  myomectomy  was  impossible,  and  only  a  palliative  operation  was  ven- 
tured upon. 

M.  P.,  aged  forty-five,  white.  Oi)eration,  June  1, 1901 ;  death  on  the  same  day. 
This  })aticnt  had  had  frequent  hemorrhages  for  three  and  one-half  years  before 
her  admission.  On  May  8,  1901,  her  last  period  began,  and  continued  until  her 
admission  to  the  hospital.  She  had  grown  very  weak,  and  had  been  losing 
ground.  For  the  previous  two  weeks  she  had  had  symptoms  of  fever.  She  was 
a  very  large,  fleshy  woman.  Her  lips  and  mucous  membranes  were  markedly 
blanched;  the  respirations  were  shallow,  and  she  looked  very  ill.  There  was 
a  blowing  systolic  murmur  at  the  apex.  The  hemoglobin  was  20  per  cent.  On 
palpation  a  rounded  tumor  was  found  filling  the  entire  abdomen.  The  cir- 
cumference of  the  abdomen  measured  115  cm.  On  vaginal  examination  the  out- 
let was  found  greatly  relaxed.  There  was  a  free  bloody  discharge.  The  cervix 
was, in  the  normal  position.  The  external  os  was  greatly  dilated.  Palpation 
through  the  external  os  revealed  a  necrotic  mass  near  the  anterior  surface.  Under 
light  anesthesia  thorough  curettage  was  done,  and  fully  a  liter  of  foul  blood-clots 
removed  from  the  uterine  cavity.  The  cavity  was  then  irrigated  with  salt 
solution  and  lightly  packed.  The  patient  was  returned  to  the  ward  in  fairly 
good  condition.  Toward  evening  the  pulse  became  irregular,  the  respirations 
shallow,  and  she  soon  died. 


Final  Results  after  Vaginal  Myomectomy. 
Letters  were  sent  out  to  all  patients  that  recovered  from  the  original  operation, 
and  in  48  of  the  79  cases  we  have  data  as  to  the  subsequent  history: 

Suljseiiucnt  hysterectomy  necessary 2  cases 

Subsequent  operation,  nature  not  known 1  case 

Development  of  carcinoma  of  the  body  five  years  hiter 1       " 

Recurrent  fibroids 1       " 

Deatli  from  intercurrent  affection  fourteen  and  fifteen  years  later 2  cases 

Patients  not  well S       " 

Patif  iits  well  at  periods  varying  from  a  few  months  to  fifteen  years 33       " 


48  cases 
Subsequent  pregnancy 2  cases 


VAGINAL    MYOMECTOMY.  585 

Hysterectomy  Subsequent  to  Vaginal  Myomectomy. — In  Case  1317  the  ])ationt 
was  thirty-tlircc  years  of  age.  On  Apfil  11,  1S92,  a  blackish-red,  strangulated 
myoma,  about  11  cm.  in  diameter,  was  found  filling  the  vagina.  This  mass  was  so 
friable  that  the  greater  portion  was  easily  broken  do\Mi  with  the  finger.  On  the 
third  day  the  temperature  reached  104°  F.,  but  she  left  the  hospital  after  a  month, 
feeling  well. 

When  the  patient  reentered  the  hospital  eighteen  months  later  (Gyn.  Xo. 
2183)  the  vagina  was  filled  with  a  large,  sloughing,  offensive  mass,  which  pro- 
truded from  the  cervix.  This  was  removed,  and  twenty  days  later  the  large 
myomatous  uterus,  which  extended  as  high  as  the  umbilicus,  was  taken  away 
through  an  abdominal  incision.  The  patient  left  the  hospital  very  much 
improved. 

Fifteen  years  after  the  first  operation  she  wrote:  ''My  health  is  very  bad." 
She  was  very  weak  and  nervous,  and  often  had  attacks  in  which  she  fell.  The 
nervous  phenomena,  however,  had  been  prominent  l^efore  her  first  admission 
to  the  hospital. 

In  Case  9196  the  patient  was  forty-seven  years  of  age  and  entered  the  hospital 
on  November  5,  1900.  Projecting  from  the  cervical  canal  was  a  pedunculated, 
smooth,  submucous  myoma.  This  was  readil}^  removed,  and  with  the  curet  a 
large  amount  of  mucosa  was  brought  away.  Recovery  was  without  incident. 
Several  months  later  the  patient  entered  a  hospital  in  Staunton,  Yii.,  and  was 
curetted  on  account  of  uterine  hemorrhage.  This  gave  relief  for  a  few  weeks. 
She  then  returned  to  Baltimore  and  had  her  uterus  removed. 

Path.  No.  6319  demonstrates  clearly  the  cause  of  the  persistent  bleeding. 
The  uterus  was  the  seat  of  a  typical  diffuse  adenomyoma.  The  complete  details 
of  the  gross  and  histologic  examination  of  the  uterus  are  found  in  "  Adenomyoma 
of  the  Uterus."  p.  99. 

Other  Operations  Subsequent  to  Vaginal  Myomectomy. — In  Case  5133  the 
patient  was  forty-eight  years  of  age.  She  entered  the  hosi)ital  on  March  26.  1897. 
Projecting  from  the  cervical  canal,  and  attached  by  a  [H'dicle  1  cm.  in  diameter, 
was  a  submucous  myoma  3x5  cm.  This  was  readily  removed,  and  tlic  patient 
made  a  good  recovery.  In  a  letter  from  her  ten  years  later  siie  said  that  she  iiad 
since  had  two  other  operations,  ])ut  further  imiuiiy  faih-d  to  elicit  their  nature. 
Her  general  health  was  fair. 

Vaginal  Myomectomy  ;  Hysterectomy  Five  Years  Later  on  Account  of  Adeno- 
carcinoma of  the  Body  of  the  Uterus. — Gyn.  No.  3295.  Aged  forty-five.  Fnteivd 
the  hospital  on  January  24,  1S95.  The  vagina  was  filled  with  a  smooth,  hard 
conical  mass.  This  was  readily  removed  and  the  patient  discharged  on 
February  23d. 

Gyn.  No.  7699.  On  April  4,  1900.  a  complele  alxlominal  hysterectomy 
was  done  for  adenocarcinoma  of  tlie  body,  wliich  ai)pari'ntly  had  originated  just 
above  the  internal  os.     Situated  near  the  right  cornu  was  an  interstitial  myoma, 


586 


MYOMATA    OF   THE    UTERUS. 


3  cm.  in  diameter.  This  case  is  reported  in  detail  in  the  chapter  on  Adeno- 
carcinoma of  the  Body  of  the  Uterus,  p.  280. 

"Recurrent  Fibroids."  On  p.  585  we  mentioned  Case  1317,  in  which,  after 
the  removal  of  a  large  submucous  mj'-oma,  the  patient  reentered  the  hospital 
eighteen  months  later  and  had  a  second  suhiiiueous  myoma  excised.  A  few 
weeks  later  hysterectomy  was  })erformed. 

In  Case  5496  the  patient,  aged  forty,  hrst  entered  the  hosjiital  on  September 
3, 1897.  Filling  the  vagina  was  a  large,  cauliflower-shaped,  sloughing  and  friable 
submucous  m^'oma.  The  removal  of  this  was  complicated  by  excessive  hemor- 
rhage. The  patient  rapidly  gain(>d  strength  and  left  the  hospital  on  September 
30,  1897.  On  several  subsecjuent  occasions  other  submucous  myomata  were 
removed.     The  case  is  described  in  detail  in  the  chapter  on  iSarcoma  (p.  252). 

The  patient  wrote  on  January  9,  1907,  more  than  nine  years  later,  that  her 
general  health  was  good,  but  that  she  had  a  constant  uterine  discharge. 

Late  Deaths  Following  Vaginal  Myomectomy. — Two  of  the  48  patients  con- 
cerning whom  the  subseciuent  history  has  been  learned  are  dead.  One  (Case  909) 
died  fifteen  years  after  operation,  of  some  unknown  cause.  The  other  (Case 
1551)  died  fourteen  years  after  operation,  of  cerebral  hemorrhage.  Neither 
of  these  deaths  can  be  in  any  way  attributed  to  the  operation. 

Patients  Alive,  but  not  well  After  Vaginal  Myomectomy. — From  the  accom- 
panying table  it  will  be  seen  that  S  of  the  patients  are  not  well,  but  in  only  2  of 
these  (No.  12079  and  San.  No.  1593)  is  there  evidence  of  pelvic  disease.  In 
San.  No.  1593  it  looks  verv  much  as  if  the  uterus  contained  other  mvomata. 


No. 

Years  Since  Oper- 
ation. 

Pelvic  Disease. 

Cause  of  Illness. 

4663 

Ten. 

No. 

5242 

Ten. 

No. 

Pain  in  chest  and  knees. 

8410 

Six. 

No. 

10376 

Four. 

No. 

10872 

Three. 

No. 

Nervousness. 

12079 

One. 

Yes. 

Pain  in  left  side  of  pelvis. 

12591 

One. 

No. 

San.  1593 

Three. 

Yes. 

Still   menstruating   at   fifty-four; 
weak  and  dizzy. 

IS 

Patients  Remaining  Well  After  Vaginal  Myomectomy. — Of  the  48  patients 
al)out  whom  we  have  been  able  to  obtain  the  necessary  data,  33  are  well  at 
periods  varying  from  six  months  to  fifteen  years.  This  demonstrates  conclusively 
that  in  many  cases  the  uterus  contains  only  one  myoma,  and  that  after  its 
removal  the  patient  may  have  no  further  uterine  trotible. 


VAGINAL    MYOMECTOMY 


587 


TABLE  OF  VAGINAL  MYOMECTOMIES— PATIENTS  REMAINING  WELL. 


Case  No. 
1150 
1489 
1610 


Years  After 
Operation-. 

Fifteen. 
Fifteen. 
Fourteen. 


1716  (Weight  at  operation  70    Fourteen. 

pounds,  now  160.) 

2182  Thirteen. 

2593  Thirteen. 

2666  Thirteen. 

4165  Eleven. 

5296  .                           Ten. 

5687  Nine. 

6002  Nine. 

614.3  Nine. 


6441 
6604 
6833 
6855 
7010 
8159 
8517 


Eight. 

Eight. 

Eight. 

Eight. 

Seven. 

Six. 

Six. 


Years  .Xfter 

Case  No. 

QPERATIO.N'. 

8600 

Six. 

8831    (Now  a 

myoma 

Six. 

1  cm.  at 

junction 

of     cervix     and 

body.) 

9137 

Five. 

9875 

Three. 

10618 

Four. 

San.  1497 

Three. 

10635 

Four. 

11243 

Three. 

C.H.I.  J. 

Three. 

C.H.I.  409 

Two. 

11889   (Almost 

Two. 

moribund.) 

12257 

One. 

13014 

One-half. 

C.H.I.  1201 

One-half. 

Pregnancy  Following  Removal  of  a  Submucous  Myoma. — In  two  of  our  48 
patients  pregnancy  has  occurred.  One  (Case  1489),  aged  thirty-live,  was  ad- 
mitted on  July  23,  1892.  Her  menses  had  been  irregular,  occurring  at  intervals 
of  from  four  to  nine  weeks.  Six  weeks  previous  to  her  admission  she  noticed 
a  tumor  in  the  left  ovarian  region.  This  was  not  tender.  l)ut  apparently  in- 
creased rapidly  in  size.  On  vaginal  examination  a  small  submucous  myoma 
was  found.  The  uterus  was  the  seat  of  an  early  pregnancy.  The  myoma 
was  readily  removed.  On  the  third  day  the  temperature  readied  102.2°  V..  l)ut 
dropped  to  normal  ])y  the  tenth  day.  The  pregnancy  was  in  no  way  inlerfei-ed 
with. 

The  patient,  wi'iting  fifteen  years  later,  state(l  that  her  health  was  good, 
and  that  she  had  been  deliN'ered  of  the  one  child.  The  conception  in  this  case, 
or  course,  antedated  tlie  operation. 

In  Gyn.  No.  6002  the  patient  was  thirty-four  years  of  age.  She  entei-ed  the 
hospital  on  April  5,  1898,  complaining  of  a  moi'e  of  less  contimious  bloody 
vaginal  discharge,  which  she  had  had  U)V  thi'ee  years,  '['he  \agina  was  tilled 
with  a  large,  hard,  firm,  rounded  mass,  about  11  cm.  in  diameter.  The  uterus, 
which  was  small,  was  })erched  on  the  toj)  of  the  mass.  The  tninor  was  remo\"ed 
chiefly  by  morcellation  and  the  piMhcie  conlriilleij  with  catgut.  l\ec()\-ei-_\-  was 
prompt,  although  the  |)atient  was  anemic 

Nine  years  later  the  |)atient  wrote  that  she  had  had  perfect  health  e\-er  since. 
She  also  said  that  since  the  operation  she  had  had  one  child,  and  that  the  birth 
was  an  easv  one. 


CHAPTER  XXXI. 
ABDOMINAL  HYSTEROMYOMECTOMY. 


Local  Applications  as  a  Means  of  Checking  Hemorrhage. — A  few  3'ears  ago  it 
was  custoniary  to  apply  astringents  to  the  uterine  mucosa,  with,  the  idea  of  check- 
ing the  bleeding,  \\lien  the  uterine  cavity  was  small  and 
readily  accessible,  this  doubtless  had  some  temporary  value, 
but  in  the  majority  of  the  cases  it  is  impossible  to  reach  all 
portions  of  the  uterine  cavity  with  any  instrument,  and  then 
there  is  always  the  danger  of  losing  the  cotton  pledget  of  the 
applicator,  as  in  Fig.  342,  or  of  setting  up  a  pelvic  inflamma- 
tion. With  the  splendid  technic  as  now  perfected,  operation 
certainly  gives  the  patient  a  much  better  prospect  of  recovery 
than  does  any  method  of  local  treatment.  When  the  uterus 
is  freely  movable,  the  operative  mortality  is  ver}-  low.  Where 
pus-tubes  are  associated  with  myomata,  local  ai)j)lications  are 
contraindicated. 

Electrical  Treatment  for  Myoma  Cases. — Our  e.\i)erience  in 
this  field  has  been  practically  nil.  It  is  supposed  that  electric 
applications  check  hemorrhage  and  in  some  instances  diminish 
the  size  of  the  tumor.  A  glance  at  the  various  hgures  showing 
the  sizes  and  sliapes  of  the  uterus  and  the  distorted  uterine 
canals  that  are  tluis  so  frequently  found  in  myoma  cases  wiW 
convince  the  reader  that,  even  if  electricity  has  a  beneficial 
effect,  in  many  cases  it  would  be  impossible  for  the  })hysician 
to  reach  any  appreciable  i)ortion  of  the  uterine  cavit}-  with 
his  instrument. 

The  following  case  that  was  under  Apostoli's  care  for  a 
considerable  period  is  of  interest,  l^lectricity  certainly  had 
a  temporary  effect,  but  it  \nll  be  noted  that  after  cessation  of 
the  treatment  the  bleeding  recurred  and  he  finally  advised 
hysterectomy. 

Our  examination  of  this  uterus  after  removal  showed  little 
or  no  alteration  in  the  myomata,  and  tlic  mucosa  was  i)racti- 
call}'  normal. 


Fig.    342.— .\    Gacze 
Swab    Found    in 
THE  Cavity  of  a 
Myomatous  Ute- 
rus.   (Nat.  size.) 
S..  C.    H.  I.    De- 
cember 15,   1906.     .\t 
operation   we   found   a 
foul,   offensive  uterine 
discharge    and    an    ir- 
regular, greenish  mass, 
about  1.5  cm.  in  dia- 
meter, lying  free  in  the 
uterine     cavity.     The 
artist     in       sketching 
the  hardened  specimen 
chipped   off   the   outer 
layer  and  detected  the 
gauze  network  as  seen 
at  a.     At  b  the  coagu- 
lated    blood     is     still 
present. 

The  consultant 
who  had  attempted 
to  check  the  uterine 
hemorrhage  had  ap- 
plied chromic  acid  to 
the  uterine  mucosa, 
and  the  pledget  had 
evidently  dropped  off 
the  probe.  The  foul 
discharge  greatly  in- 
creased the  dangers  of 
the  operation. 


J.  Path.  No.  3674 

J.  J.,  seen  December  *),  180'.).     In  188.3  the  patient  suffered 
from  a  severe  degree  of  prostration  and  had  fever  for  sixty  days.    She  had  constant 

588 


ABDOMINAL    HYSTEROMYO.MKCTOMY. 


589 


alxloimnal  pain  aiitl  i)rofuso  monstruation.  The  bleeding  shortly  after  this  l)ecanie 
excessive,  and  she  had  almost  total  loss  of  memory.  Dr.  Ajwstoli  gave  her  electric 
treatment,  and  she  returned  much  improved.  In  1SS7  she  went  back  to  Paris 
for  more  electric  treatment,  and  again  experienced  relief,  but  later,  at  Carlsbad, 
she  had  profuse  menstruation.     This  was  again  checked  by  electric  treatment. 

In  1891  Dr.  Apostoli  found  her  very  ill,  and  did  not  expect  her  to  recover. 
In  1897  electric  treatment  was  again  started  and  tlie  bleeding  ceased  during  the 
treatment,  but  recommenced  and  continued  when  the  electricity  was  stopi)ed. 
Apostoli  advised  operation,  but  the  patient  refused.  When  she  camc^  under  our 
care  the  patient  had  constant  headache  and  profuse  hemorrhages,  and  liml  l)een 
in  bed  one  week  of  each 
month.  The  uterus  was 
removed  by  one  of  us 
(Kelly)  December  9,  1899, 
and  the  patient  recovered. 

Path.  No.  3674.  The 
specimen  consists  of  a  myo- 
matous uterus,  slightly  ir- 
regular in  shape,  measuring 
10  X  10x13  cm.  (Fig.  343). 
The  outer  surface  is  smooth 
and  glistening,  and  some- 
what roughened.  Scat- 
tered throughout  the  uter- 
ine wall  are  numerous 
myomata,  the  largest  7 
cm.  in  diameter. 

The  uterine  cavity  is 
approximately  10  cm.  in 
length,  and  in  places,  es- 
pecially in  the  neighljor- 
hood  of  the  cervix,  is  almost 

obliterated,  as  well  as  much  distorted  by  the  submucous  nodules.  To  introduce 
a  stiff  catheter  or  an  instrument  far  u])  into  such  a  uterine  cavity  would  be 
almost  an  impossibihty.  The  uterine  nuicosa  is  smooth.  Over  the  submucous 
nodules  it  is  as  thin  as  ])archment,  but  where  not  subjected  to  pressure,  reaches 
2  or  3  nun.  in  thickness.  None  of  the  myomata  gives  any  macroscoj-tic  evidence 
of  disintegration. 

Histologic  Examination.— The  uteiine  mucosa  pi'esenlsa  wavy  and  tuuhilating 
appearance,  and  has  an  intact  surface  epithelium.  ( )\-er  the  prominent  portion 
of  the  submucous  myomata  the  mucosa  is  thiiuied  out  and  consists  merely  of  a 
narrow  layer  of  stroma  covered  witii  epillieiiiun.  but  dexoid  of  glands.  In  the 
protected  areas  betw(>en  nodules  ilie  mucosa  is  slightly  tliickened;    the  glands 


Fig.  343. — A  Myomatous  Utervs  after  Years  ok  Electric  Treat- 
ment. 

Path.  No.  3674.  This  patient  was  given  intra-uferine  electric  treat- 
ment by  Apostoli  in  1885  with  relief,  and  again  in  1887,  1891 .  and  1897 
respectively.     Hysterectomy  was  performed  iby  Kelly)  in  1899. 

As  seen  from  the  history,  the  electric  treatment  temporarily  checked 
the  bleedings,  but  they  recurred.  The  uterus,  on  removal,  was  10  x  10x13 
cm.  From  the  contour  of  the  uterine  cavity  it  is  evident  that  no  local 
api)lications  could  possibly  have  reached  all  jiortions  of  the  interior  of 
the  uterus.  It  must  be  admitted  that  the  growth  was  a  slow  one,  as  it 
had  been  under  observatinn  fur  fourlci'ii  \cars. 


590  MYOIMATA    OF   THE    UTERUS. 

are  numerous,  convoluted,  and  in  ])laces  moderately  increased  in  caliber.  The 
gland  epithelium  is  intact,  slightly  swollen,  but  somewhat  flattened.  These  en- 
larged glands  have  little  tufts  of  stroma  projecting  into  their  cavities,  and  these 
tufts  are  also  covered  with  epithelium.  The  picture  is  one  of  gland  hypertrophy. 
The  stroma  of  the  nmcosa  is  sparsely  sprinkled  with  small  round  cells,  and  in 
the  superficial  ])ortions  there  is  some  hemorrhage.  The  mucosa,  taken  as  a  whole, 
is  normal.  The  myoniata  show  a  few  areas  of  hyaline  degeneration,  but  are  other- 
wise unaltered. 

It  will  be  seen  from  the  foregoing  that  the  electric  treatment  had  caused  no 
I)ermanent  alteration  in  either  the  mucosa  or  the  myomata.  Gland  hypertrophy 
is  a  common  accompaniment  of  uterine  myomata,  and  hyaline  degeneration 
of  the  tumor  is  invariably  found. 

Indications  for  Operative  Interference. — Long  experience  has  taught  that 
myomata,  if  let  alone,  may  reach  large  proportions  and  give  rise  to  pressure 
symptoms,  and  that  if  they  become  submucous,  alarming  and  occasionally 
fatal  hemorrhage  may  ensue.  In  some  of  our  cases  the  subperitoneal  or  intra- 
ligamentary  myomata  had  suppurated  and  opened  into  the  intestines  or  caused 
a  peritonitis.  Submucous  tumors  occasionallj^  undergo  disintegration  that  in 
some  instances  leads  to  a  fatal  issue;  hyaline  and  cystic  changes  have  been 
frequently  noted.  In  over  1  per  cent,  of  the  cases  sarcoma  had  either  de- 
veloped in  or  been  associated  with  the  myomatous  growth,  and  in  nearly  2  per 
cent,  of  our  cases,  carcinoma  of  the  body  of  the  uterus  in  addition  to  the 
myomata  was  found. 

Judging  from  these  findings,  the  surgeon  would  naturally  infer  that  all 
myomata  should  be  removed.  It  must  be  remembered,  however,  that  many 
patients  have  small  myomata  that  occasion  no  discomfort  whatsoever,  and  are 
detected  only  during  the  routine  examination  made  when  the  woman  is  being 
treated  for  .some  intercurrent  affection. 

If  a  patient  has  a  small  myomatous  uterus  that  is  apparently  ciuiescent 
and  occasioning  no  discomfort,  it  is  wise  to  let  well  enough  alone;  but  should 
the  periods  be  increasing  in  duration  and  be  very  free,  submucous  myomata  are 
probably  present,  and  the  advisability  of  a  myomectomy  or  hysterectomy  should 
be  carefully  considered  while  the  patient  is  still  in  good  condition.  Again, 
whenever  the  tumor  ajjjx'ars  to  be  growing  rapidly,  it  should  be  removed.  The 
presence  of  a  myomatous  uterus  two  or  three  times  its  natural  size,  when  un- 
accompanied by  any  discomfort,  is  no  indication  for  operation.  The  patient 
should,  how^ever,  be  kept  under  observation,  reporting  to  the  physician  at  least 
four  times  a  year. 

The  Anesthetic— In  nearly  all  our  cases  at  the  present  time  ether,  preceded 
by  gas  or  ethyl  chloride,  is  the  anesthetic  used,  the  ether  being  administered 
by  the  drop  method.  Since  doing  away  with  the  cone  we  have  been  surprised 
at  the  marked  diminution  in  the  amount  of  postoperative  vomiting. 


ABDO-AIIXAL    HYSTEROMYOMECTOMY. 


591 


Occasionally  when  the  patient  has  bronchitis  or  an  old  })k'urisy  chloroform 
is  used. 

In  Case  11944  the  abdomen  was  opened  with  the  patient  under  t lie  influence 
of  Schleich's  solution,  the  incision  extending  from  the  ensiform  to  the  pubes. 


r 


«> 


Fig.  344. — The  Myomatous  Utkris  riiioR  to  Kkmoval. 
A  liberal  incision  gives  good  exposure,  facilitates  the  operation,  and  prevents  the  bruising  of  tissues  that  may 
occur  where  very  strong  traction  is  necessary.  Where  it  is  advisable  to  remove  the  aijpendages  with  the  tumor, 
the  round  ligaments  are  first  clamped  and  cut,  and  then  the  ovarian  vessels  are  doubly  clamped,  as  indicated, 
and  cut  between  the  clamps  The  uterus  can  thon  bo  liftcil  fartlicr  u|i\vard,  and  tlic  uterine  vessels  located 
after  the  bladder  has  been  pushed  down. 


592 


.MVOMATA    OF   THH    UTERUS, 


After  the  tumor  was  delivered,  the  patient  eoiiiphiined  bitterly  of  an  indes- 
cribable feeling  of  unrest  and  ainioyance,  although  there  was  no  pain.  The  oper- 
ation was  conijileted  untler  general  anesthesia. 

In  San.  No.  2142  the  patient  had  a  mitral  insuffieieney.    The  entire  o})eration, 


Fig.  345. — Amputatio.v  Through  the  Cervix. 
The  left  round  ligament,  the  left  ovarian  vessels,  and  the  left  uterine  vessels  have  been  cut  between  clamps. 
The  right  round  ligament  and  the  ovarian  vessels  have  likewise  been  controlleil.     The  cervix  is  being  drawn 
strongly  upward  and  to  the  right  with  mesoforceps,  and  is  being  severed.     When  the  amputation  is  completed, 
it  will  only  be  necessary  to  clami)  the  right  uterine  vesse  s  and  the  tumor  can  be  removed. 


ABDU.MIXAL    HYSTEROMYOMIXTO.M Y, 


593 


which  histed  an  hour,  ^vas  pcrfoniiod  with  nitrous  oxide  gas  as  the  anesthetic, 
with  thorough  satisfaction. 

Taking  all  in  all,  we  have  found  ether  the  safest  and  most  satisfactory  anes- 
thetic. 


.'(An  Eav 


Fig.  346. — Tm:  Api'i.akance  of  thk  Pki.vis  Wiikn   vi.i.  tiii;  ("audiwi.  Vksski.s  havk  bi:i:>J  Clampkd  and  tiik 

TU.MOK    ReMOVKI). 

The  anterior  lip  of  the  cervix  is  gra.specl  with  Jacob's  forceps,  and  the  uterine  ves.sels  \vitl>  Wcrtheini's'chinipN, 
the  ovarian  vessels  with  Kocher-Ochsner  clamps,  and  the  round  ligaments  with  curved  artery  forceps.  For  the 
appearance  of  the  tuiimr  with  its  attached  clamps  see  Fig.  347. 


Supravaginal   Hysterectomy  and   Panhysterectomy  in    Myoma  Cases. — Con- 
siderable diffcivncc  of  (.pinion  exists  as  to  whether  supravaginal  hysterectomy 
or  total  removal  of  the  uteinis  should  he  cniM-iiMl  out  when  niyoiii;ita  exist.     .Viter 
38 


594  MYOMATA    OF   THE    UTERUS. 

carefully  weighing  the  advantages  and  the  disadvantages  of  each  operation,  we 
have  adoi)ted  8ui)ravagiiial  hysterectomy  as  the  usual  procedure. 

Su[)ravaginal  aiiiinitation  is  the  easier  operation,  especially  in  difficult  cases, 
where  it  is  almost  iin])()ssil)l('  to  expose  the  cervix  and  the  uterine  vessels.  In 
this  operation  there  is  nuich  less  danger  of  injuring  th(>  ureters,  and  less  tendency 
to  the  production  of  cystitis.  When  a  portion  of  the  cervix  is  saved,  the  ends 
of  the  round  ligaments  may  be  inserted  into  it,  and  a  good  buttress  for  the  pelvic 
contents  is  thus  formed,  which  diminishes  the  tendency  to  prolapse  of  the  pelvic 
contents.  Panhysterectomy  is  much  safer  whenever  sarcomatous  degeneration 
of  the  uterus  is  suspected  (p.  195)  or  when  carcinoma  of  the  body  of  the  uterus 
complicates  uteiine  myomata  (p.  276).* 

When,  as  in  Case  8114,  the  cervix  is  so  small  that  no  stump  can  be  left,  com- 
plete hysterectomy  is  not  only  a  wise  procedure,  but  the  only  possible  one.  In 
other  cases  the  cervix  may  be  unfolded  by  a  large  submucous  cervical  myoma, 
as  in  Case  9798  (Fig.  40,  {).  57).  Here  it  was  necessary  to  completely  remove 
the  uterus. 

In  some  cases  large  subnuicous  myomata  filling  the  vagina  distend  it  and  lift 
the  uterus  up.  In  such  cases  the  vagina  is  easily  opened  up,  and  it  is  manifestly 
simpler  to  do  a  complete  hysterectomy.  Cases  10995  and  C.  H.  I.,  R.  are  good 
examples  of  such  a  condition. 

Taking  all  in  all,  and  making  due  allowance  for  the  possibility  of  occasionally 
encountering  sarcoma  or  carcinoma,  we  feel  that  supravaginal  hysterectomy 
is  the  better  operation  to  adopt  in  the  majority  of  the  cases.f 


Simple  Abdominal  Hysteromyomectomy  with  Preservation  of  the  Tubes 

AND  Ovaries. 

Where  abdominal  hysterectomy  is  deemed  advisable  in  patients  before  the 
menopause,  and  where  the  appendages  are  normal,  it  is  our  duty  to  save  the 
ovaries  on  both  sides  if  possible.  If  the  uterus  is  relatively  movable,  it  may  be 
removed  in  one  of  two  ways: 

1.  By  first  tying  the  cardinal  vessels  as  they  are  encountered  and  then  re- 
moving the  uterus. 

*  Inspection  of  the  Uterine  Cavity  for  Carcinomd  and  the  Myomata  for  Sarcoma  before  Suturing 
the  Cervix. — We  have  elsewhere  strongly  emphasized  the  necessity  for  opening  up  the  uterine 
cavity  just  as  soon  as  the  tumor  is  removed,  to  exclude  the  presence  of  carcinoma  of  the  body, 
as  it  has  been  associated  with  myomata  in  25  of  our  cases  (see  p.  277). 

On  p.  190  is  described  in  detail  a  case  in  which  we  had  amputated  through  the  cervix  and  a 
typical  sarcoma  was  present  in  the  myoma.  Section  of  this  myoma  would  have  instantly  demon- 
strated the  malignant  growth.  It  was  overlooked,  and  the  patient,  two  years  later,  had  an  in- 
operable growth  in  the  cervix.  Whenever  a  malignant  growth  is  found,  the  cervix  should  be 
excised  at  once. 

t  GVowp  Operations. — On  p.  526  we  have  coiisiden'd  the  various  other  operations  that  were 
performed  in  addition  to  a  myomectomy.  In  quite  a  number  of  our  hysterectomy  cases  other 
disorders  required  surgical  interference.  The  necessarj'  procedures  were  undertaken  at  the  same 
time,  or.  when  the  patient  was  too  weak,  after  an  interval  of  several  weeks. 


ABr)(  )MIXAL    HYSTEROMYOMECTOMY. 


595 


2.     By  clamping  ihc  canlinal  vessels  as  they  are  encountered,  removing  the 
uterus,  and  then  applying  the  ligatures. 


Fig.  347. — The  Uterus  as  it  Ai'i>t:.\HS  on  JIemovai^  When  all  the  Vessels  have  ueen  Oontuolled  with 

Clamps  and  Cut. 

The  cervix  is  grasped  with  mesoforceps,  the  uterine  vessels  with  Wertheini  clamps,  the  round  liKanients  with 

curved   artery   forceps,   and    the   ovarian   vessels   with    Kocher-Ochsner   forceps. 


Tying  the  Cardinal  Vessels  as  They  are  Encountered  and  Then  Removing  the 
Uterus. — The  usual  steps  arc: 

1.  Tying  the  left  round  liiiaiiicnt  nii  the  tlistal  ami  claiiipiii^  on  ihe  proxi- 
mal side  and  severiii";. 


596 


MVO.MATA    OF   THK    UTERUS. 


2.  Ligating  the  left  ovarian  and  tubal  vessels  on  the  pelvic  side  near  the 
uterus,  clamping  on  the  uterine  side,  and  cutting  between  the  clamps. 

3.  Separating  the  vesical  peritoneal  fold  from  the  anterior  surface  of  the 
uterus,  from  the  round  ligament  on  the  left  to  the  round  ligament  on  the  right. 

4.  Separating  the  folds  of  the  left  l)road  ligament  until  the  left  uterine 
vessels  are  seen  or  felt.  Ligating  the  uterine  vessels  on  the  pelvic  side,  clamping 
on  the  uterine  side.    Severing  the  uterine  vessels  between  the  clamps  and  ligating. 

5.  Ligating  and  suturing  the  right  round  ligament. 

6.  Ligating  the  right  ovarian  and  tubal  ve-ssels  near  the  uterine  horn  and 
cuttiiiir  th(>  tube  and  ovarv  from  the  uterine  cornu. 


Fig.   348. — Appkarance   of   the    Pelvis   after   all   the   Cardinal  Vessels  have  been  Controlled. 
The  ovarian  and  uterine  vessels  on   both  sides  have  been  tied,  and  the  anterior    and  posterior  lips  of    the 
cervix  are  being  approximated    by  a  figure-of-8  suture  of    catgut,  which  has  not  yet  been  tied.     The    round 
ligaments  are  temporarily  clamped  i)rior  to  their  insertion  into  the  cervical  stump. 


7.  Separating  the  right  broad  ligament  and  exposing  the  uterine  vessels, 
ligating  and  then  cutting  these  vessels. 

8.  Amputating  through  the  cervix. 

9.  Closing  the  cervical  flaps.* 

10.  The  final  toilet  of  the  pelvis  includes  bringing  the  ends  of  the  round 
ligaments  to  the  cervical  stump  and  covering  in  the  cervical  stump  with  the 
redundant  vesical  peritoneum,  thus  leaving  a  perfectly  smooth  pelvic  cavity. 

*  The  cervical  flaps  are  nearly  always  brought  together  with  catgut.  In  a  few  of  the  early 
cases  silver  wire  or  silk  was  used.  As  a  rule,  the  cervical  stump  is  not  over  3  or  4  cm.  in  diameter, 
but  in  a  small  number  of  cases  the  raw  area  to  be  approximated  may  be  very  large. 


ABDOMINAL    HYSTEIIOM  YO.M  i:( 'TOM  V 


597 


By  tying  and  sovorino;  the  left  round  ligament  the  broad  ligament  is  at  once 
opened  up,  and  the  uterus  ean  be  lifted  still  further  out  of  the  abdomen.  The 
"clear  space"  beneath  the  tubal  vessels  is  well  exjxjsed,  and  a  ligature  is  at  once 
carried  through  it,  the  ovarian  and  tubal  vessels  being  controlled  a  short  dis- 
tance from  the  uterine  horn.  In  this  ligature  are  included  the  inner  end  of  the 
tube  and  the  utero-ovarian  ligament,  in  addition  to  the  vessels.  The  combined 
mass  is,  however,  relatively  small.  Some  emijloy  only  catgut  for  this  ligature, 
but  it  is  safer  to  use,  for  all  cardinal  vessels,  a  fine  Pagenstecher  reinforced  by  a 
second  consisting  of  catgut.  Clamps  are  now  applied  to  the  uterine  horn,  and 
the  tube  and  ovary  severed  from  their  uterine  attachment  It  is  necessary  to 
have  forceps  that,  when  once  applied,  will  remain  //;  s{(i(  and  not  s])riiig  off  or 


Ov.  vess.  V 


Fig.  349. — Drawinc;  thk  Utkrixk  Vessels  into  the  C'ekvical  Silmt. 
The  uterine  and  ovarian  vessels  on  both  sides  have  been  ligated,  and  the  round  ligaments  are  controlled 
with  forceps.  The  left  uterine  vessels  have  been  drawn  over  and  included  in  the  last  cervical  ligature  on  that 
side.  The  right  uterine  vessels  are  being  drawn  over  preparatory  to  including  them  in  the  last  suture  on  the 
right  side.  This  method  is  frequently  adopted,  and  offers  ailditioiial  security-  against  hemorrhage  from  the 
uterine  vessels. 


slip.     Ochsner's    modification    of    Koehei-'s    force))s    answers    this    ret'iuirement 
perfectly. 

In  opening  up  the  left  l)road  Hgameiit  only  a  scant  amount  of  connective 
tissue  is  encountered.  This  is  rapidly  snipped  with  the  scissors,  or  can  be  readily 
dissi])ated  by  gently  sej)arating  with  the  two  index-fingers  drawn  away  from 
each  other.  If  the  posterior  peritoneal  layer  of  the  broad  ligament  is  cut  down- 
ward toward  the  cervix  for  ai»out  half  an  inch,  ihe  ulerus  can  be  bi'ought  still 
further  upward,  and  the  uterine  \'essels  are  bellei'  e\|)osed.  During  this  dis- 
section it  is  atlvantageous  I  ha!  a  lighl  he  placed  on  I  he  opposil  e  side  of  t  he  broatl 
ligament,  so  that,  if  any  impoitaiit  si  iiicluicsare  in  danger,  they  can  be  seen  by  the 
transmitted  light.      \\  hen  cutting  the  ])ostei'ior  peritoneal  llap,  it  is  well  to  keep 


598 


MVOMATA    OF   THE    ITKRUS. 


close  to  the  uterus  and  not  to  cut  too  far  down,  as  the  ureter  might  be  severed. 
The  left  uterine  artery  with  its  accompanying  veins  is  now  exposed  and  can  l)e 
readily  tied.  A  round  curved  needle  is  used.  It  is  inserted  close  to  the  cervix, 
so  that  the  vessels  are  not  punctured;  in  fact,  it  may  pass  through  the  outer 
margin  of  the  cervix.  After  both  ligatures  have  been  tied,  a  clamp  is  applied 
about  an  inch  above,  and  the  vessels  severed  between  the  clamj)  and  the  liga- 
tures. 

The  steps  on  the  opposite  side  are  similar  to  these  already  described. 

Prior  to  cutting  across  the  cervix,  the  abdominal  incision  and  the  surrounding 
pelvic  contents  are  carefully  walled  off  with  gauze.  The  operator  makes  strong 
traction  on  the  uterus  and  cuts  across  the  cervix  with  a  knife,  or  preferably  with 
a  Kelly  spud  (Fig.  345).     As  he  does  this,  he  cups  out  the  cervix  slightly  or  leaves 


Fig.   350. — Insertion   of  thk   End   of  the   Round  Ligament  into  the  Cervical  Stump. 
The  central  part  of  the  cervical  stump  has  been  approximated.     On  the  right  the  round  ligament  has  been 
brought  into  the  angle  of  the  cervix.     On   the  left,  the   suture  which  accomplishes  this  has  been    introduced, 
but  not  drawn  taut  and  tied.     The  remaining   raw  areas   are   then    approximated,    as   shown    in  Fig.  352.     The 
stumps  of  the  ovarian  vessels  are  seen 


a  concave  surface,  so  that  it  really  forms  the  anterior  and  j)()sterior  flaps,  which 
can  be  approximated.  There  should  be  very  little  bleeding,  as  all  the  main 
vessels  have  already  been  controlled.  The  cervical  stump  is  grasped  with  a 
Jacob's  forceps  and  drawn  upward.  If  the  remaining  cervical  mucosa  shows 
any  signs  of  inflammation,  it  is  advisable  to  dilate  the  cervical  canal  well,  so  that 
there  may  be  good  drainage,  or,  still  better,  remove  most  of  the  cervical  mucosa 
with  the  uterus,  as  advocated  by  one  of  us  (Kelly),  and  as  sho^^^l  in  Figs. 
353,  354. 

The  anterior  and  posterior  surfaces  of  the  cervical  stump  are  now  approxi- 
mated with  catgut.     The  last  suture  on  the  right  and  that  on  the  left  includes 


ABDO:\IIXAL    H YSTEKOM VO.MECTOM Y. 


599 


the  stump  of  the  coiTospoiidino;  uterine  artery  (Fig.  349),  thus  (lou])ly  minimizing 
the  chance  of  secondary  hemorrhage  from  these  vessels. 

The  round  ligaments  are  now,  if  of  sufficient  length,  brought  do\Mi  and  fastened 
to  each  other  and  to  the  cervical  stump  (Figs.  350,  351,  352).  The  stumps 
comprising  the  inner  ends  of  the  tubes  and  the  utero-ovarian  ligaments  with  the 
vessels  are  covered  over  with  broad  ligament   i)erit()neum,  and  the  cervix  is 


A^ 


^^^^ 

4-- 

in 

^ 

^VM 

Htm- 

M^ 

■    H 

■L'                                                            w^H 

W% 

I^HB^^^^^^^^^ 

^           -^^^ 

&t    ...v..^-**- 

.tfSaH^ 

i^ii 

Ik.,    ool. Al'PEARANCE    OF    THE    FsLVIS    AFTKR    Sf  HHWAUINAL    H  YSTKBKCTOM  Y. 

The  cervical  suture  line  is  usually  from  left  to  rifcht,  but  here  it  has  been  in  the  anteroposterior  direction 
The  ends  of  the  round  ligaments  are  brought  together  behind  the  cervix,  to  minimize  the  danger  of  prohipsus, 
and  the  iimer  ends  of  the  ovaries  have  been  apiiroxiinated.  All  raw  areas  have  Ijeen  controlled,  so  that  there  L* 
little  danger  of  postoperative  intestinal  adhcsi(nis.     (For  the  usual  methoil  of  closure  sec  I'ig.  '.i^y'2.) 


covered  over  with  vesical  ])erit()neum.  Tn  this  final  covering  over  of  the  areas 
with  peritoneum  fine  needles  and  line  catgut  arc  necessary,  on  account  of  the 
delicate  character  of  the  peritoni'uui,  and  care  imisi  be  cxci-ciscd  not  to  pierce 
any  artery  with  the  iicc(llc-|)oiiit  or  to  ])!-ick  t  lie  ui-ctci-  or  iiicliidc  it  in  one  ot  t  lie 
peritoneal  flaps. 

Prior  to  closing  the  cervix,  the  operator  has,  of  course,  re(iuested  an  assistant 
to  open  the  uterine  cavity  to  exclude  the  possibility  of  c;nicer  of  the  body.     The 


600 


:VIYOMATA    OF   THE    UTERUS. 


uterine  myomata  have  also  been  examined  to  see  if,  ])ert'luince,  a  sarcomatous 
degeneration  can  be  found.  If  either  early  process  should  happen  to  be  present, 
the  cervix  should  be  removed  at  once.  For  a  full  discussion  of  this  point  see 
p.  179. 

The  appendix  is  now  examined  and  the  abdomen  closed. 

Clamping  of  the  Cardinal  Vessels,  Removal  of  the  Uterus,  and  the  Apphcation 
of  the  Ligatures. — If  the  surgeon  has  had  little  experience  in  abdominal  hysterec- 
tomies, it  is  advisable  to  tie  the  vessels  as  he  encounters  them,  l)ut  one  who  is 


Bladder-perit.covering 
e  e  r  V.  stump 


Biiried    stump  of  ov.  vess.- 


Fig.  352. — Appearance  of  thk  Pelvis  after  Insertion  of  the  Round  Ligament  into  the  Cervical  Stump. 
The  round  ligaments  have  been  brought  into  the  angles  of  the  cervix,  as  indicated  in  Fig.  350.     The  bladder 
peritoneum  is  then  drawn  over  the  cer\-ix  and  snugly  sutured  to  its  posterior  surface.     The  stump  of  the  ovarian 
vessels  and  the  remaining  raw  areas  are  covered  in  with  peritoneum  by  means  of  continuous  sutures. 

doing  hysterectomies  frccjuently  can  save  much  time  by  temporarily  clamping 
the  vessels  and  tying  them  after  the  uterus  has  been  removed. 

Where  clamps  alone  are  used,  it  is  absolutely  necessary  to  employ  those  that 
will  not  slip,  otherwise  alarming  hemorrhage  may  result.  Figs.  344,  345,  346 
show  the  most  satisfactory  kinds  of  artery  forceps.  The  various  steps  in  the 
operation  are: 

1.  Clamping  the  left  round  ligament  on  the  outer  side  and  clamping  on  the 
inner  side,  severing  the  round  ligament  and  then  opening  up  the  left  broad  liga- 
ment. 


ABDOMINAL    HYSTKllU.MYO.MIXTU.MV, 


GOl 


2.  Clamping:;  the  left  ovarian  and  tnl)nl  vessels  near  the  uterus,  separating 
the  tube  and  ovary  from  the  uterus. 

3.  Opening  uj)  the  left  broad  ligament  and  freeing  tlie  bladder  from  the 
uterus. 

4.  Doubly  clamping  and  cutting  the  left  ulerine  vessels. 

5.  Clamping  and  severing  the  right  round  ligament. 


Fio.  353. — ExTENSivK  Removal  of  the  Cervical  Mucosa  where  Supravaginal  Hystkr^ci-omv  is  1'krkorxied. 
When  the  clinical  findings  strongly  suggest  an  infection  of  the  cervical  mucosa,  it  is  advisable  to  remove  as 
much  of  this  as  is  feasible.  The  uterus  is  freed  on  all  sides,  and  the  cervix  severed  circularly  almost  to  the  mucosa. 
The  dissection  is  continued  downward  until  most  of  the  mucosa  lining  the  canal  has  been  freed,  as  indicate^!.  Two 
provisional  sutures  held  in  the  directions  of  the  arrows  prevent  retraction  of  the  cervix.  A  clamp  across  the  cervix 
prevents  any  escape  of  the  uterine  contents.  The  uterus,  which  is  held  merely  by  the  cervical  mucosa,  is  liberateti 
by  means  of  the  thermocautery.  The  operation  is  finished  in  the  usual  manner.  One  of  us  (Kelly)  has  been 
using  this  method  with  much  satisfaction  for  several  years. 


6.  Clamping  and  se\'ei-iiig  the  i-jght  tulie;iiid  owiry  fit»iii  the  uterus  at  the 
cornu. 

7.  Spreading  the  right   bi'oad  hgaiiieiit  and  ehimpiiig  the  iitei'ine  \"esse]s. 

8.  Amputating  the  uterus  at  the  cervix. 

9.  Ligating  the  left  ovarian,  h'I't   uterine,  riglit   utei'ine,  and  lighi   (i\arian 
vessels  in  the  order  mentioned. 

10.  Closing  the  cervical  stump,  luinging  I  he  ends  ol'  the  round  hgaineiit  into 
the  suture  line  if  possible. 


602 


-MVOMATA    OF   THH    ITKKUS. 


11.     Covering  over  all  raw  areas  with  jjeriloiieiim. 

It  is  always  well  to  elaini)  aiul  cut  the  round  ligaments  at  once,  as  cutting 
them  permits  the  operator  to  lift  the  uterus  still  further  out  of  the  alKlomen  and, 
furthermore,  the  clear  space  in  the  broad  ligament  is  at  once  seen.  One  l)lade  of 
the  artery  forceps  may  be  at  once  push(Ml  through  this,  and  the  ovarian  and  tubal 
vessels  controlled.  A  clamp  is  now  applied  to  the  uterine  cornu,  and  the  uterus 
is  severed  from  its  tubal  and  ovarian  attachments.  The  bladder  reflection  is 
now  picked  up  and  easily  separated  by  sli])ping  the  scissor  blade  beneath  the 
itladdcr  pei-itoneum.  and  severing  it  from  left   to  right  or  the  reverse.     The  peri- 


M  u  <"  0  s  a 


drawn/ 


Fici.  3o4.—  Extensive  Removal  of  Cervical  Mucosa. 
Where  there  seems  to  be  danger  of  infection  from  the  cervical  mucosa,  the  mucous  membrane  is  sometimes  dis- 
sected out,  in  the  manner  indicated,  and  removed  prior  to  closure  of  the  cervical  lijjs. 

t(jneum  is  very  thin  and  translucent,  and  if  it  cari'ies  blood-vessels  of  any  appreci- 
able size,  these  are  seen  at  once. 

The  left  broad  ligament  is  now  widely  opened,  and  the  uterine  vessels,  after  a 
little  blunt  dissection,  are  readily  seen  or  felt.  They  are  now  doubly  clamped 
with  Wertheim  parametrial  forceps,  and  the  vessels  cut  between  the  clamps 
(Fig.  345).  The  structures  on  the  right  side  are  handled  in  the  same  order,  and 
the  cervix  can  then  be  cut  acro.ss  with  little  or  no  hemorrhage. 

The  clamps  cent  nulling  the  vessels  are  now  replaced  by  ligatures.  For  each 
group  of  vessels  we  usually  employ  one  Pagenstecher  reinforced  by  one  catgut 
ligature. 

Wherever  there  is  the  slightest  danger  of  infection  fr(jm  the  cervical  canal,  the 
abdominal  incision  and  the  pelvic  contents  should  be  most  carefully  walled  off 
before  the  cervix  is  severed.  The  cervical  flaps  are  now  brought  together, 
and,  where  possible,  the  ends  of  the  round  ligaments  sutured  into  the  cervical 


ABDOMIXAL    HYSTERDM  Y(  )M  i:(T(  ).M  V 


603 


stump.  All  raw  areas  are  now  covered  over  with  peritoneum,  and  after  careful 
sponging  of  the  pelvis  the  abdomen  is  closed. 

The  Employment  of  the  Round  Ligaments  in  the 
Suspension  of  the  Cervical  Stump  . — In  those  cases  in  which  the 
cervix  tended  to  sag  down  into  the  vagina,  after  bringing  the  cervical  flaps  to- 
gether we  have  drawn  the  ends  of  the  round  ligaments  down  to  the  cervix  and 
sutured  them  there,  as  indicated  in  Figs.  350, 351, 352.  The  peritoneum  has  then 
been  sutured  over  the  cervix.  By  this  means  the  cervix  has  been  held  well  up 
in  the  vaginal  vault.    This  method  is  similar  to  that  advocated  by  other  surgeons. 

The  Preservation  of  One  or  Both  Ovaries  in  Cases  of  Hysteromyomectomy. — In 
at  least  125  of  our  cases  one  or  both  ovaries  were  saved.  Tiial  we  might  ascer- 
tain the  effect  of  such  preservation  upon  the  general  health,  letters  were  sent  out 
to  these  patients.  Fifty-six  (37  white  and  19  colored)  replied,  giving  fairly 
complete  answers.  The  chief  object  was  to  ascertain  in  what  percentage  of  the 
cases  an  artificial  menopause  had  been  avoided,  special  attention  being  paid  to 
the  presence  or  absence  of  hot  flushes.  In  order  to  absolutely  exclude  any  al> 
normally  early  appearance  of  the  menopause  we  have  included  only  those  cases 
in  which  the  patients  were  not  over  forty-one  years  of  age.  A  study  of  the 
accompanying  table  will  show  the  essential  data  obtained. 


Hot  Flushes. 

Age  at 
Opera- 
tion. 

Present 
Age. 

48 

Case  No. 

Present  or 
Absent. 

Earliest  Appearance 
After  Operation. 

Duration. 

Present 
Health. 

3340 

36 

Present . 

Fourteen 

Ft)ur  years. 

(lood. 

months. 

4635 

37 

48 

" 

Not     mentioned. 

Still  persist. 

\'ery  good. 

4832 

28 

39 

ti 

Several  years. 

Still     persist 
(  e  \'  e  r  y     two 
weeks). 

\'ariable. 

5239 

39 

49 

" 

A  few  months. 

Still     oreasionally 
present . 

I'^xeellent. 

5277 

31 

41 

It 

(lOOtl. 

5325 

35 

45 

" 

Several    months. 

Several  months. 

Poor. 

6372 

40 

49 

Eight  years. 

Oeeasionally  pres- 
ent. 

( lOod. 

6972 

38 

4() 

" 

P'ive  years. 

One  year. 

Poor. 

7696 

30 

■M 

Absent. 

\ Cry  gootl. 

7703 

29 

•M\ 

Present. 

Two  years. 

Still    occasioiiiilly 
present . 

\  ery  good. 

8306 

36 

42 

Absent. 

|-;.ir. 

8705 

39 

45 

" 

\'ery  good. 

9029 

38 

44 

Present . 

Sniin  alter. 

Still  persist. 

(Jood. 

9078 

36 

42 

Absent. 

Ciood  exi('i)t  for 
ovarian     |)ain 
at  period. 

9286 

37 

43 

li 

I'.Tfe.-l. 

9527 

36 

41 

" 

I''airlv  i:ood. 

9788 

32 

37 

Present. 

Iniinciliatcly    al'- 
Irr  (i|>it:iI  ion. 

Six  months. 

Poor! 

9818 

40 

45 

Ab.senl. 

(iood. 

9843 

29 

34 

" 

( lood. 

9928 

40 

45 

Present . 

Six  inoiit  lis. 

Ilirrc       to       lour 
<l;.y>. 

( iood. 

604 


MYOMATA   OF   THE   UTERUS. 


.\gk  .\t 

Hot  Flcshes. 

Case  No. 

Opkr.\- 

Present 

Present 
He.\lth. 

TION. 

Age. 

Present  or 

Earliest  Appearance 

Duration. 

38 

42 

Absent. 

After  Operation. 

10357 

Prp.sent . 

F'oiir  years. 

Still  persist. 

Good. 

10453 

36 

40 

Absent . 

Good. 

10558 

38 

42 

Present . 

A  few  weeks. 

Still  persist. 

Fair. 

10580 

27 

31 

Absent. 

(iood. 

l()(i<>7 

3S 

42 

" 

Poor. 

hjk; 

•  )- 

.SO 

Pre.sent. 

Two  months. 

Still  persist. 

Poor. 

11217 

41 

44 

Ab.sent. 

Very  good. 

11392 

34 

37 

Present . 

Three  weeks. 

Still  persist. 

Poor. 

1 1472 

3S 

41 

One  year. 

Still    oceasionally 
present. 

Good. 

11681 

33 

36 

Ab.sent. 

Fairly  good. 

11688 

39 

42 

Present. 

Two  montlis. 

Still     occasionally 
present. 

Good. 

11722 

33 

36 

Absent . 

Fairly  good. 

11984 

41 

43 

'' 

\'ery  good. 

12086 

37 

38 

'' 

Ciood. 

12185 

38 

40 

" 

(lOOtl. 

12301 

24 

26 

Present. 

Not  mentioned. 

Not  mentioned. 

Fair. 

12369 

27 

29 

Absent . 

Good. 

12488 

41 

43 

Pre.sent. 

One  montli. 

Four  months. 

Perfect. 

12522 

34 

36 

Sixteen    months. 

Still    occasionally 
present . 

Fair. 

12525 

28 

30 

" 

One  month. 

Still  persist. 

Good. 

12696 

28 

30 

Ab.sent. 

Ciood. 

12764 

24 

25 

Gootl. 

12937 

41 

42 

" 

(iood. 

12944 

43 

44 

Present . 

.\  few  weeks. 

Still  persist. 

Ciood. 

13039 

27 

28 

" 

Six  months. 

Still  persist. 

Fair. 

C.   H.   I., 

382 

37 

40 

u 

Three  mf)nths. 

Four  months. 

Good. 

C.   H.   I., 

392 

32 

35 

Ab.-<ent. 

Good. 

C.   H.   I., 

620 

35 

37 

" 

Perfect . 

C.    H.    I.. 

673 

36 

38 

Present. 

One  month. 

Still  persist. 

Fair. 

C.  H.   I., 

949 

39 

41 

Al)sent. 

Fair. 

C.   H.   I., 

1095 

29 

30 

Present. 

( )nc  inontli. 

Still  persist. 

Ciood. 

San., 

1691 

40 

43 

Absent . 

Ciooil. 

San.. 

1702 

40 

43 

" 

Ciood. 

San., 

1773 

37 

40 

Present. 

.After  operation. 

Six  months. 

\'ery  good. 

San.. 

2144 

39 

40 

" 

Sevenil  months. 

Still  persist. 

Good. 

San., 

2Hi4 

38 

39 

.\l>sent. 

Fair. 

H  o  t  !•'  1  u  s  h  e  s  .  — Twcnty-niiic,  cjr  51.8  per  cent.,  of  the  })ati('iits  .suffered 
from  hot  flushes  of  varying  severity  and  duration.  These  in  most  instances 
appeared  at  the  time  the  menstrual  flow  would  normally  have  been  present.  In 
4  of  the  29  cases  (4832,  6372,  6972,  and  10357)  the  hot  flushes  did  not  appear  for 
several  years  after  operation.  Of  \hrsr  patients,  2  were  forty-nine  and  forty- 
seven  years  old  respectively  when  the  iiot  fhi.^iies  occurred.  This  was  un- 
rloul)tedly  the  period  when,  under  normal  conditions,  their  menopause  would 


ABUO.MIXAL    HYSTEROMYOMECTO.MY.  605 

have  been  reached.  In  Cases  6972  and  10357  the  women  were  forty-three  and 
forty-two  years  old  respectively  when  the  hot  flushes  appeared,  and  although 
they  were  still  under  forty-five  years  of  age,  the  phenomena  strongly  suggested 
the  onset  of  the  normal  menopause.  By  excluding  these  4  cases  from  our  tabu- 
lation we  find  that  in  only  25,  or  44.6  per  cent.,  of  the  56  were  hot  flushes  or  indi- 
cations of  the  menopause  present. 

In  Case  9928  the  patient  was  forty  years  old.  Hot  flushes  appeared  six 
months  after  operation  and  lasted  only  a  few  days.  She  is  now  forty-five  years 
old,  and  has  had  no  reappearance  of  symptoms  suggestive  of  the  menopause. 

In  3  cases  hot  flushes  appeared  only  occasionally.  In  6  cases  hot  flushes 
occurred  after  operation,  but  continued  only  for  a  few  months. 

In  several  cases,  however,  the  hot  flushes  occurred  more  frequently  and  were 
of  much  longer  duration.  In  Case  3340  the  woman  was  thirty-six  years  old.  Hot 
flushes  appeared  fourteen  months  after  operation,  and  were  present  each  month 
for  four  years  In  Cases  9029  and  10558  hot  flushes  appeared  soon  after  operation 
and  still  persisted  six  and  four  years  later  respectively.  In  12  cases  hot  flushes 
appeared  during  periods  of  from  one  to  three  years  after  operation,  and  still 
persisted.  Thus  in  only  15  of  the  56  cases  were  there  hot  flushes  of  motlerate 
severity  which  persisted  for  a  long  period. 

Even  if  we  exclude  the  4  cases  in  which  no  hot  flushes  were  present  for  se^•eral 
years  and  were  not  noted  before  what  appeared  to  be  the  normal  menopaus(\  we 
still  have  27  cases,  or  48.1  per  cent.,  in  which  no  hot  flushes  have  ever  been  noted. 
This,  to  our  mind,  demonstrates  conclusively  that  the  surgeon  should,  wherever 
possible,  save  every  normal  ovary.  In  some  instances,  of  course,  when  the 
ovaries  are  h^ing  high  in  the  abdomen,  although  it  might  be  surgicalh' feasible  to 
spare  them,  their  retention  might  materially  increase  the  risk. 

Vicarious  Menstruation.  — Efforts  were  also  made  to  ascertain 
if  in  any  way  the  menstrual  function  was  retaincxl.  In  2  cases  (8705  and  9527) 
bleeding  from  the  nose  w^as  noted  at  the  time  inciistiuntioii  would  normally 
have  been  ])resent.  Both  of  thes(>  jiaticuts  prior  to  operation  had  not  been 
subject  to  bleeding  from  the  nose.  In  one  of  these  cases  (8705)  bleeding  oc- 
curred at  the  second  month  after  operation,  hut  lU'X'er  rea|)peai"ed.  in  Ca.se 
9527  bleeding  from  the  nose  a{)peare(l  each  month  for  several  months.  In 
neither  of  these  cases,  however,  is  mention  made  of  tiie  duration  or  th(>  amount 
of  bleeding. 

In  4  cases  vaginal  bleeding  wasjjresent.  Cndoubtedly  in  these  cases  there 
had  been  a  high  amputation  of  the  uterus,  a  small  jjortion  of  tlie  uterine  mucosa 
remaining,  which  at  the  menstrual  jn-riod  continued  to  pei'form  its  normal  func- 
tion. In  3  of  these  cases  the  vaginal  bleeding  was  ii'i'egular  and  lasted  but  a 
short  time.  The  fourth  case  (9286)  is  most  inteivsiing.  Three  years  after 
operation  menstruation  reappeared,  and  has  continueil  each  nioiuh  for  the  j)ast 
two  years.     The  quantity  of  flow  is  slight. 

Present      Health     of     Patients.       In  36  of  the  ca.ses  the  health 


606 


MYOMATA    OF   THE   UTERUS. 


is  ''good";  in  13,  "fair";  and  in  7,  "poor."     In  only  4  cases  were  the  symptoms 
directly  rcfcraMc  tn  the  |»cl\is 

Simple  Left  to  Right  Abdominal  Hysterectomy  with  Removal  of  the  Appen- 
dages.—When  it  is  deemed  advisable  to  remove  the  tubes  and  ovaries  with  the 
uterus,  the  technic  carried  out  may  be  similar  to  that  described  on  p.  600,  the 
only  difference  being  that  the  ligatures  or  clamps  applied  to  the  ovarian  and 
tubal  vessels  control  these  vessels  to  the  outer  or  pelvic  side  of  the  ovary,  instead 
of  near  the  uterine  horn. 


Fig.  355. — .\  Diagrammatic  Representation  of  the  Left  to  Right  Operation. 

This  represents  a  hysterectomy  after  the  menopause,  otherwise  the  ovaries  would  not  have  been  removed. 
First  the  left  ovarian  vessels  are  controlled  and  cut,  then  the  left  round  ligament.  The  bladder  is  now  freed, 
and  the  left  uterine  vessels  are  controlled.  The  cervix  is  cut  across,  the  right  uterine  vessels  are  clamped  and 
severed,  and  the  uterus  is  rolled  out.  The  right  round  ligament  is  clamped  and  cut.  The  right  ovarian  vessels 
are  controlled,  and  the  uterus  is  removed. 

The  numbers  and  arrows  indicate  clearly  the  line  of  procedure,     (.\fter  n(nvard  A.  Kelly.) 


Several  years  ago  one  of  us  (Kelly*)  described  a  method  which  materially 
simplifies  hysteromyomectomy.  It  is  usually  spoken  of  as  the  "left  to  right," 
or  "right  to  left,"  operation  (Fig.  355). 

The  usual  steps  in  the  operation  are  the  following: 

1.  Suturing  and  severing  the  left  round  ligament. 

2.  Doubly  clamping  and  cutting  the  left  ovarian  vessels  (Fig.  344). 

3.  Freeing  the  bladder  from  the  uterus. 

4.  Blunt  dissection  of  the  left  broad  ligament  and  double  clamping  of  the 
left  uterine  vessels. 

*  H.  A.  Kolly,  .lohiis  Hopkins  Hosp.  Bull.,  Kcl)ni;iry,  1896. 


ABDOMINAL    HYSTKHOM YOMKCTO.M Y.  607 

5.  Aiin)iitati()n  of  the  uterus  through  the  cervix  (Fig.  345j. 

6.  Champing  the  right  uterine  vessels  and  severing  these  vessels. 

7.  Clamping  the  right  round  ligament  and  right  ovarian  vessels,  severing 
them,  and  removing  the  uterus. 

8.  Tying  all  cardinal  vessels  (Fig.  348). 

9.  Closure  of  the  cervix,  with  insertion  of  the  round  ligaments  into  the 
cervical  stump  (Fig.  350). 

10.  Covering  over  all  raw  areas  with  peritoneum  (Figs.  3.")!  and  3o2j. 

In  this  operation  the  aim  is  literally  to  roll  the  tumor  out  of  the  abdomen. 
When  the  left  round  ligament  is  severed  and  the  left  ovarian  vessels  are  ligated 
and  cut,  the  bladder  is  freed  from  the  uterus;  the  uterus  is  then  drawn  strongly 
to  the  right,  and  with  gentle  dissection  the  left  uterine  vessels  are  seen  or  felt, 
and  must  be  controlled  l)y  the  most  trustworthy  clamp.s — preferably  Wertheim's. 
When  the  cervix  is  cut  across,  the  uterus  can  be  drawn  still  further  outward. 
The  lower  part  of  the  cervix  is  meanwhile  firmly  grasped  with  mesoforceps  by  an 
assistant  to  prevent  it  from  receding.  As  the  knife  severs  the  final  cervical 
fibers  on  the  right,  great  traction  is  exerted  and  a  certain  amount  of  stretching 
of  the  tissues  enables  the  operator  to  grasp  the  uterine  vessels  at  a  higher  level. 
These  once  severed,  the  uterus  can  be  rolled  out,  and  after  the  round  ligament 
and  the  ovarian  vessels  have  been  clamped,  the  uterus  is  free.  All  cardinal 
vessels  are  now  controlled,  the  cervix  is  closed,  and  all  raw  areas  are  covered 
over  with  peritoneum. 

In  each  case  some  minor  modifications  may  be  necessary.  For  instance,  in 
some  cases  when  there  is  not  room  to  apply  two  forceps  to  the  left  ovarian  vessels, 
it  may  be  necessary  to  ligate  the  vessels  and  then  cut,  the  vessels  on  the  uterine 
side  being  grasped  as  they  are  cut.  Again,  when  the  operation  is  likely  to  be 
a  long  one  or  when  it  may  be  necessary  for  the  operator  to  witluh-aw  without 
doing  a  complete  operation,  it  is  often  wise  to  tie  all  vessels  as  they  are  encoun- 
tered. WTiere  it  is  very  difficult  to  get  a  point  of  cleavage  on  the  left  side,  the 
removal  may  be  started  on  the  right  and  carried  to  the  left.  In  this  operation 
the  more  difficult  side  is  always  left  until  the  last,  and  in  the  end  it  really 
becomes  the  easier  side,  as  after  severance  of  the  cervix  tli(>  uterus  can  l)e  rohed 
out  without  difficulty. 


Hysteromyomectomy  Followed  by  Immediate  Removal  of  the  Appendages. 

In  certain  cases  the  appendages  are  so  ghieil  ilown  to  the  sun-ouniHng  struc- 
tures that  their  removal  is  not  only  liaught  with  much  .langer.  but  it  is  ahnost 
imi)ossible  to  get  a  point  of  cleavage.  Where  such  a  condition  exists,  the  uterus, 
as  a  rule,  is  not  very  large.  This  is  nvidily  understood,  because  if  the  uterus  had 
reached  large  })rop()rtions,  the  appendages  would  liaM'  Iteeii  lit'led  high  into  the 
abdomen,  and  then  control  would  have  been  easier. 

In  such  cases  two  m(>thods  of  treat  nieiil  are  available: 


608  MYO.MATA    OF   THK    ITERUS. 

1.  Hysterectomy  with  iiimicdiato  iiMiioval  of  the  appendages. 

2.  Bisection  of  the  utci'us. 

Wherever  possible,  hysterectomy  is  preferable,  bisection  being  reserved  for 
those  cases  in  which  hysterectomy  is  otherwise  impossible. 

Hysterectomy  with  Immediate  Removal  of  the  Appendages.— The  uterus  is 
firmly  grasped  with  strong  mes()forcei)s.  and  any  vantage  once  gained  by  the 
traction  is  never  yielded.     The  following  steps  are  then  taken: 

1.  ('lami)ing  and  cutting  of  the  left  ai)pendages  at  the  uterine  horn. 

2.  Tying  and  severing  the  left  round  ligament. 

3.  Separating  the  bladder  reflection. 

4.  Exjiosing,  clamping,  and  severing  the  left  uterine  vessels. 

5.  Cutting  across  the  cervix. 

G.     ('lami)ing  and  severing  the  right  uterine  vessels. 

7.  Clamping  and  severing  the  right  round  ligament,  the  right  appendages 
at  the  uterine  horn  and  removing  the  uterus. 

8.  Liberating  the  left  ai)])endages  from  Ix-low  upward,  clamping  the  ovarian 
vessels,  and  removing. 

9.  Liberation  of  the  right  ajjpcndages.  Clamping  of  the  ovarian  vessels; 
removal. 

10.  Tying  all  the  cardinal  vessels. 

11.  Closure  of  the  cervix,  with  insertion  of  the  round  ligaments  into  the 
stump  if  feasible. 

12.  Closure  of  all  raw  areas. 

13.  Drainage  through  the  vagina  if  raw  areas  cannot  ho  covered,  or  if  there  is 
much  danger  of  infection. 

By  removing  the  uterus  first,  the  adherent  ai^pendages  can  be  gotten  at  from 
the  under  side  and  dissection  carried  on  under  sight.  Before  this  procedure  was 
adopted  the  rectum  was  much  more  fretiuently  injured.  Naturally,  clamping 
the  vessels  instead  of  tying  them  during  removal  of  the  uterus  is  preferable,  as  in 
the  later  steps  of  the  operation  the  tying  of  the  vessels  fvu'ther  out  would  make 
the  first  ligatures  superfluous. 

Recently  one  of  us  (Kelly)  has  cupped  out  the  cervix  to  a  marked  degree  in 
those  cases  in  which  infiammation  of  the  cervical  nuicosa  is  susi)ected.  From 
Figs.  353  and  354  it  will  be  noted  that  the  cervical  mucosa  is  dissected  free  almost 
to  the  external  os.  It  is  then  clamped,  so  that  none  of  the  cervical  contents  can 
escape  to  contaminate  the  cervical  stump,  and  then  cut  across  below  the  clamp. 


Bisection  of  the  Uterus. 

In  a  certain  number  of  cases  the  o))erator,  on  opening  the  abdomen,  feels 

completely   baffled    to   find    the    uterus   sitting    on    the    top    of    a     myoma, 

which  fills  the  pelvis  (Fig.  356),  or  that  the  uterine   tumor    fits  the  pelvis  so 

accurately    and    is   so    fixed    by    adhesions    that    the    usual    operative   pro- 


ABDOMIX AL    II YSTEHOM VO.M Kl  TOM Y. 


009 


cedures  are  futile.     Or,  as  in  Case  9G78,  a  large  jielvic  al)scess   may  add  to 
the  difficulty. 

In  such  cases  l)isection,  as  described  Ijy  one  of  us  (Kelly),*  in  1900,  enables 
the  operator  in  a  few  minutes  to  overcome  the  chief  obstacles,  and  enucleation 
can  then  be  effected. 

As  seen  on  p.  683,  the  mortality  in  this  operation  is  high.  In  myoma  ca.ses 
it  is  never  to  be  resorted  to  when  the  utcn-us  can  be  removed  intact,  and  is  to  be 
studiously  avoided  whenever  the  chance  of  sarcomatous  degeneration  of  a  myoma 
exists,  or  when  there  is  a  possibility  of  carcinoma  of  the  body  being  present. 

It  is  but  natural  that  the  mortality  should  he  high,  as  it  is  only  in  desperate 
and  otherwise   inoperable   cases   that  the 
operation  is  to  be  performed.     The  steps 
of  the  operation  are  as  follows : 

1.  Grasp  each  side  of  the  fundus  with 
strong  mesoforceps  and  make  firm  traction 
upward  (Fig.  357). 

2.  Cut  directly  through  the  center  of 
the  tumor  until  the  vesical  reflection  is 
reached. 

3.  Dissect  down  the  vesical  reflection, 
the  assistant  meanwhile  keei)ing  up  the 
strong  traction. 

4.  Continue  the  bisection  imtil  the  cer- 
vix is  reached  (Fig.  358). 

5.  Cut  to  the  left  until  the  uterine 
vessels  are  nearly  exposed,  meantime 
making  very  strong  traction  on   the  left 

half  of  the  uterus  (Fig.  359).     Doubly  chimp   the  left    uterine  vessels  and  cut 
between  forceps. 

6.  Roll  out  the  left  half,  clamping  in  succession  the  left  round  ligaments  and 
the  left  ovarian  vessels  (Fig.  300). 

7.  Cut  across  the  right  half  of  the  ceiA'ix  until  the  t  uinor  is  nearly  fre(\  Clainj) 
the  right  uterine  vessels  and  cut. 

8.  Clamp  the  right  round  ligament  and  the  right  ovarian  vessels  in  succession 
and  deliver  the  right  half  of  the  uterus. 

9.  Ligate  the  cardinal  \'essels. 

10.  Clos(^  th(>  cervical  flaps. 

11.  C()\-er  all  raw  areas  with  peritoneum,  and  diaiii  ihiough  the  \'agina 
if  it  be  deeineil  necessary. 

It  is  a  well-known  fact   that  strong  traction  greatly  diininish(\'<  hemoi-rhage, 

*  Howard    A.  Kelly,   A    Preliminary    Report    on     tlie    Surgical    Treatment   of  Complicateil 
Fibroid  Tumors  of  the  Womb,  with  a  Description  of  Two^Iethods  of  Operating,  Johns  Hopkins 
Hosp.  Bull.,  1900,  vol.  xi,  p.  56. 
39 


Fig.  3.56. — Bisection  ok  the  Uterus. 
The  arrow  indicates  the  Une  of  bisection. 


610 


MYOMATA    OF   THE    UTERUS. 


SO  there  should  Ix'  lui  let  up  on  the  mcsoforceps  from  the  time  bisection  is  com- 
menced until  the  two  halves  of  the  uterus  have  been  delivered. 

Sometimes  it  is  onl}-  necessar}'  to  continue  the  incision  until  a  large  myoma 
has  been  bisected  and  .shelled  out  (Fig.  361).  In  such  cases  the  uterus  may  then 
collapse,  and  the  operation  is  converted  into  a  simple  one  (Fig.  362),  the  uterus 
being  easilv  removed  in  the  usual  way  from  left  to  right. 


-•%. 

% 


/ 


Fig.  357. — First  Steps  in  Biskction  of  the  Uterus 
The   fundus   has   been  firmly  grasped    on    the    right    and    left    with    mesoforceps.     The    bladder    is    being 
dissected  free  and  pushed  down  preparatory  to  bisection  of  the  organ.     The  myomatous  uterus  has  purposely 
been  drawn  small,  so  that  the  various  steps  can  be  more  readily  followed. 


In  other  cases,  even  after  bisection  and  shelling  out  of  the  uterus,  dense  ad- 
hesions are  found  fixing  it  to  the  pelvic  floor.  These  adhesions  are  now  carefully 
dissected  free  from  liclow  upward  under  sight. 

As  a  rule,  the  ojKTation  is  not  accomi)anied  by  much  hemorrhage,  but  if  in  the 
bisection  the  knife  cuts  too  far  to  one  .side,  large  venous  .'minuses  or  big  branches 
of  one  or  other  uterine  artery  may  l)e  cut,  and  alarming  hemorrhage  follow. 


ABDOMINAL    HYSTEROMVCJ.MIX'TO.M Y. 


Oil 


We  cannot  be  too  emphatic  in  sayinfj  that  this  operation  should  be  employed 
only  where  no  other  method  is  feasible. 

On  the  other  hand,  l)isection  is  of  the  greatest  assistance  to  the  surgeon  in 


tmiMWT'vr^  4 


lit,.    358. BiSKCTION    OK    THK    UtKRDS. 

The  uterus  has  been  bisected  almost  to  the  cervix.  The  ine«of«rceps  now  Kra>|is  caoh  li.-ilf  of  tin-  iilorus 
about  its  middle.  A  pair  of  artery  forceiJS  in  the  uterine  cavity  insures  culling  in  llie  iiiidhnc,  thus  avoiilinK 
either  uterine  artery.     The  appendages  are  embedded  in  adhesions. 


cases  in  which  hysterectomy  is  necessary,  on  account  of  densely  adherent  jius- 
tubes.  In  such  cases  there  is.  as  a  rule,  lillle  dnn.^er  from  s|)lilling  the  uterus. 
The  adlu^sioiis  ai'e  then  ;il  t;icke(|  fioni  thcii'  under  side,  and  a  x'ei'y  dillicult 
or  impossil)le  removal  of  the  ulei'us  is  rendered  conipai'.'iliNcly  easy,      j-'or  such 


612 


.MYO.MATA    OF   THK    UTERUS. 


cases  bisection  is   uiul()ul)l('(lly    the   easiest   operation,   and   yields   the  lowest 
mortality. 

Abdominal  Hysteromyomectomy  from  Below  Upward,  Transverse  Section 
of  the  Cervix  being  the  First  Step. — One  of  us  (Kelly*)  when  o{)erating  upon 
a  very  coinplicated  myomatous  uterus,  found  it  so  firmly  fixed  that  its  removal  by 


Fio.  359. — Bisection  of  the  Uterus. 
The  left  half  of  the  uterus  has  been  amputated  through  the  cervix.     This  portion  of  the  cervix  is  drawn 
strongly  upward  with  mesoforceps.  and  the  left  uterine  vessels  are  damped.     'I'he  left   half  of  the  uterus  is  now 
rolled  completely  out,  clamped  at  the  uterine  horn,  and  removed 

any  of  tiie  usual  methods,  or  even  by  biseetion,  was  out  of  the  (juestion.  A 
novel  plan  was  then  adojjted.  Fortunately,  the  eervix  was  fairly  accessible. 
The  bladder  reflection  was  at  once  separated,  and  the  cervix  firmly  grasped  with 
mesoforceps    (Fig.    863).     It    was   then   severed   transversely,  and   the   uterine 

*  Howard  A.  Kelly,  A  Prcliininary  Report  on  the  Surgical  Treatmoiit  of  Complicated  Fil)roid 
Tumors  of  the  Womb,  with  a  Description  of  Two  Metliods  of  Operatiiis;.  Jolms  llopUins  Hosp. 
Bull.,  1900,  vol.  xi,  p.  56. 


ABDOMIXAL    HYSTERO.MYOMECTO.MY 


613 


vessels  were  grasped  on  either  side  (Fig.  364).  The  cervix  lKiviii<r  l)eeii  cut 
through  and  the  broad  ligaments  opened,  the  round  ligaments  were  next  cut,  the 
ovarian  vessels  clamped  and  cut  and  the  densely  adherent  tumor  wtis  then  freed 
from  its  pelvic  attachments.  The  abdominal  com])lications  were  then  readily 
dealt  with,  first  because  they  could  be  studied  both  from  in  front  and  also  from 
behind,  and — equally  important — because  there  was  now  little  bleeding,  the 
cardinal  vessels  of  the  tumor  having  been  tied. 


(Tube     an.l 
u  t  ,    o  V.    t  i  q 


a.^  >■...., 


Fid.  ,300.     Bi.section'  or  tiik  L'tluus. 
Tlie  left  luilf  of  the  uterus  has  Ijeen  removed.     The  left  uterine  vessels  have  Ix-eii  lit-il.      Tlie  h-fl  muiiil  Hki«- 
ment  and  the  left  tubal  and  ovarian  vessels  are  controlled  with  forceps.     The  riRhl  half  of  the  uterus  is  reniovetl 
in  the  same  manner.     The  adherent  appendages  are  now  carefully  dissected  free  under  sight,  and  removed  if  nec- 
essary. 


We  cannot  better  .show  the  value  of  this  ()|)erati(m  tlinii  by  giving  in  detail 
the  first  case  that  l(>d  to  its  em])l()ynient . 

In  Case  7549  the  ])atient,  when  ])l;ice(l  on  the  t;il)h'.  had  a  small,  rapitl  pulse 
which  soon  reached  140.  .M'lcr  ihc  i-elease  of  some  omental  adhesions  a  large 
myomatous  tumor  was  found  glued  down  by  extensive  adhesions.  The  trans- 
verse colon  was  so  intimately  attached  to  it  (Fig.  !()*.),  j).  W'M  that  it  soon  l)ecame 
evident  that  continued  di-ssection  would  finallv  necessitate  an  extensive  resection 


614 


MYOMATA    OF   THE    UTERUS. 


of  the  bowel.  An  alteinj)t  was  then  made  to  leave  a  thin  layer  of  the  tumor 
attached  to  the  l)owel,  as  had  been  successfully  earned  out  in  the  previous  case.* 
The  bleeding  became  so  profuse  that  this  plan  of  procedure  had  to  be  abandoned. 
The  operator  then  turned  to  the  lower  pelvic  pole  of  the  tumor.  The  cervix 
was  grasped  with  strong  mesoforceps  and  pulled  up  within  reach.  The  vesical 
reflection  was  dissected  back,  and  the  cervix  grasped  low  down  with  a  second  pair 
of  mesoforcejis.     The  cervix  was  now  cut  transversely  from  before  backward,  con- 


FiG.  3tU  — Bisection  where  the  Uterus  Completely  Fills  the  Pelvis. 
The  myomatous  uterus  filled  the  pelvis  so  accurately  that  it  would  have  been  absolutely  impossible  to  get 
at  the  uterine  vessels.  The  vessels  at  the  uterine  horns  have  been  controlled  temporarily  to  partially  check  the 
blood-supply  to  the  tumor.  The  bliulder  peritoneum  is  being  pushed  down  jjrior  to  bisection  of  the  body  of  the 
uterus,  in  the  line  indicated  by  the  arrow  The  bisection  with  reiuoval  of  the  large  myoma  is  shown  in  Fig. 
362.     (After  Howard  A.  Kelly.) 


tinued  traction  being  made  on  both  portions.  The  cellular  ti-ssue  to  the  left 
of  the  cervix  was  then  exposed,  and  the  uterine  vessels,  although  not  yet  seen, 
were  doubly  claiiij)e(l  and  severed.  The  uterine  vessels  on  the  right  side  were 
next  controlled  in  the  same  way. 

When  these  important  vascular  trunks  had  thus  been  secured,  the  larger 
forceps  were  used  to  forcibly  drag  up  the  tumor  and  the  uterine  body,  rotating 
them  on  a  transverse  axis,  exposing  first  the  round  ligament,  then  the  ovarian 
vessels  on  the  left,  and  then  those  on  the  right  side.     These  structures  were 

♦Howard  A.  Kelly.  .Jolms  Hopkins  Hosp.  Bull.,  IS'Jl,  vol.  ii,  p.  46. 


ABDOMIXAL   HYSTERO.MYOMECTOMY. 


G15 


clamped,  and  the  whole  mass  was  disconnected  from  its  pelvic  attachment. 
The  tumor  now  remained  fixed  only  by  dense  adhesions  at  its  upper  pole. 

The  next  occurrence  was  the  rupture  of  a  large  abscess  lying  behind  and  ex- 
tending from  the  center  of  the  tumor  into  a  sac,  bordered  posteriorly  by  t  he  luiuhar 
vertebrae,  and  above  by  the  mesocolon,  and  discharging  through  a  large  opening 
into  the  transverse  colon. 

The  specimen  examined  showed  that  the  abscess  was  in  reality  a  suppurating 


I'll..    oG:.'.     Till,  Value  OF  Bi.si.iiiii.N  (.n    iiii.  Lii^iu>. 
Fig.  361  shows  the  appearance  of  the  uterus  before  the  bisection.     We  now  see  the  uterus  split  in  two.     The 
large  myoma  which  occupied  the  anterior  wall  and  blocked  the  pelvis  has  been  shelled  out,  leavinK  plenty  of  room. 
The  cardinal  vessels  can  now  be  controlled  with  ease,  and  the  hysterectomy  conipletetl  in  the  usual  manner. 
(After  Howard  A.  Kelly.) 


myoma,  which  had  become  adherent  ;ind  had  discliarged  into  \]\o  large  bowel. 
The  tumor  was  now  shelled  out  and  emiclealed  I'ldin  beliiud  ui)\vard  without  any 
injury  to  the  bowel.  The  containiiialcd  alidomiiial  caxily  and  t  lie  abscess  ('a\-ity, 
which  contained  at  least  a  liter  of  lliiek  yellow  \)\i^.  wei'e  closeil.  The  opening 
in  the  bowel  was  sutured.  An  abdominal  drain  of  iodoform  gauz(>  was  carried 
down  to  the  point  of  this  sac  and  th(^  abdomen  closed.  The  patient  made  an 
excellent  recovery,  and  only  a  small,   rapiilly  closing  (istulous  tract    remained. 


616 


.MYO.MATA    OF   THK    ITKRUS. 


Had  the  operator  not  hit  upon  this  method  of  first  amputating  through  the 
cervix  and  then  working  from  below  upward,  any  radical  procedure  would  have 
been  out  of  the  question,  and  the  ]xiticnt's  death  would  at  have  been  a 
matter  of  only  a  short  thne. 


Fig.  363. — Tkansverse  Sectio.v  of  the  Cervix  .\s  the  First  Step  i.v  Hysteromyomectomy. 
It  was  impossible  to  separate  the  myomatous  uterus  from  the  omentum  and  transverse  colon  •nnthout  great 
danger  of  losing  the  patient  on  the  table.     Fortunately,  the  cervix  was  accessible.     The  overlying  bladder  peri- 
toneum was  severed,  the  cervix  grasped  with  two  pairs  of  mesoforceps,  and  severed  transversely.     The  complete 
separation  of  the  cervix  is  seen  in  Fig.  364.     (After  Howard  A   Kelly.) 


Panhysterectomy. 
When  complete  removal  of  I  lie  uterus  is  tlceided  ii])on,  we  have  found  it  wiser 
to  control  all  vessels  as  thev  are  encountered.     We  will  describe  the  method 


ABDOMINAL    HYSTEROMYO.MKCTOMY, 


617 


of  hysterectomy  where  it  has  been  found  lulvisable  to  remove  both  ovaries  with 
the  uterus. 

1.  The  left  round  hgainent  is  tied  with  eat^ut  and  cut. 


# 


Fig.  364. — Ahdominai,  HYSTEROMYOMiicroMY  "from  Bki.ow  Ui-wahd. " 
The  cervix  wa.s  separated  transversely.  The  uterine  vessels  were  cliiinped  and  cut  and  the  ovarian  ves-xels 
clamped.  The  uterus  wa.s  then  liberated  from  its  iielvic  attachment  in  the  manner  indicate*!  hy  the  arrows. 
It  wa.s  then  rolled  out,  walled  off  from  the  ahdominai  contents  with  Rauze,  and  the  adhesions  to  the  transverse 
colon  were  attacke.i  from  their  posterior  an<i  easier  side.  Ha<l  the  al)sccss  opciiiiiK  into  ihc  l.owcl  {Vig.  10«,  p. 
143)  ruptured  before  the  uterus  ha<l  been  freed  from  the  pelvis,  the  daiiKcrs  of  a  fatal  termination  wonl.l  have 
been  infinitely  greater.      (After  Howard  A.  Kelly.) 


2.  If  the  left  ovarian  ves.«^els  are  accessible,  llicy  an-  tied  with  ra^ciistcciicr 
thread,  reinforced  with  catijut  and  cut. 

3.  The  right   round  li^aiucnt  is  tied  and  cut. 


618 


MYU.MATA    OF    THK    I'TERUS. 


4.  The  right  ovarian  vessels  are  tied  aiul  cut. 

5.  The  l)hidder  reflection  is  dissected  free  and  pushed  down. 

6.  The  left  uterine  vessels  are  tied  and  cut. 

7.  The  right  uterine  vessels  are  tied  and  cut. 


Fig.  365. — Appearance  of  the  Pelvis  after  Complete  Hysterectomy. 
The  vagina  is  walled  off  with  a  piece  of  gauze;  the  vaginal  walls  are  held  taut  by  provisional  sutures  (or  artery 
forceps)  to  prevent  infection  from  the  vagina.  The  ligated  stumps  of  the  ovarian  and  uterine  vessels  and  the 
round  ligaments  are  seen.  In  some  cases,  as  indicated  in  the  drawing,  the  ureters  are  also  clearly  visible.  The 
vaginal  walls  are  whipped  over  to  check  bleeding,  and  the  vagina  is  eitlier  drained  or  closed.  The  raw  areas  are 
then  covered  over. 


8.  The  cervix  is  gradually  dissected  free  until  the  vaginal  wall  is  seen  on  all 
sides. 

9.  The  cervix  is  freed  from  the  vagina  on  all  sides  and  the  uterus  removed 
(Fig.   365). 

10.  The  vaginal  margins  are  whipped  over  with  fine  catgut  to  control  all 
bleeding,  and  if  it  is  deemed  safe  to  close  the  vagina,  the  anterior  and  posterior 
raw  vaginal  surfaces  are  approximated. 


ABDOMINAL    HYSTEROMYOMECTOMY. 


619 


11.  The  raw  areas  in  the  pelvis  arc;  covered  over  with  peritoneum. 

The  plan  of  operation  differs  little  from  that  employed  in  the  supravaginal 
hysterectomy,  until  the  cervix  is  reached.  The  uterine  vessels  are  ligated  by 
passing  a  needle  threaded  with  Pagenstecher  thread  close  to  the  cervix,  so  as  to 
avoid  piercing  the  vessels.  A  second  suture  of  catgut  is  then  introduced  in  the 
same  way. 

After  the  uterine  vessels  have  been  cut,  the  dissection  is  carefully  carried 
do^^^lward  until  the  vagina  is  encountered.     Here  one  frequently  finds  vaginal 
veins  which  may  cause  troublesome  bleed- 
ing.    In  catching  these  vessels  great  care 
must  be  taken  to  avoid  the  ureters. 

After  the  right  uterine  vessels  have  been 
controlled  and  the  dissection  has  been 
carried  do^^m  to  the  vagina,  little  difficulty 
is  usually  encountered  in  severing  the  cer- 
vix from  the  vagina,  but,  should  there  be 
any,  a  pair  of  artery  forceps  pushed  up 
into  the  vagina  from  below  may  be  cut 
down  upon  and  the  vagina  thus  easily 
opened  (Fig.  369). 

It  is  wise  to  drain  the  pelvis  in  all  cases 
where  there  is  likelihood  that  the  uterine 
cavity  has  been  infected. 

Raw  Areas. — The  surgeon  aims  to  pro- 
duce as  few  raw  areas  as  possible,  and 
when  finishing  the  operation,  if  feasible, 
leaves  everything  covered  with  perito- 
neum (Fig.  352).  This  minimizes  the 
possibility  of  intestinal  loops  becoming 
adherent,  kinking,  and  causing  intestinal 
obstruction. 

Raw  areas  after  an  abdominal  liystcro- 
myomectomy  are  usually  (hie  to  an  accom- 
panying pelvic  infection.     Thus,  in  Case  619S  the  uterus  was  lirmly  li\e<l  to  the 
rectum.     After  operation  it  was  found  impossible  to  cox-er  the  cervical  stump, 
and  it  was  left  bare.     In  Cases  8690  and  12139  the  law  areas  were  so  extensive 
that  it  was  impossil)le  to  cover  them. 

Sometimes  the  capillary  oozing  from  the  roughened  peritoneum,  whence  an 
adherent  tube  or  ovary  has  been  liberated,  is  persistent.  This  oo/.iii^  iiia\-  be 
controlled  with  hot  gauze  left  on  for  a  few  miimtes  while  tlie  operator  is  engaged 
in  liberating  or  tying  other  structures.  If  tin*  bleeding  is  not  checked,  a  suture 
which  puckers  up  the  peritoneum  may  control  it  jjerfectly.  as  in  Case  7739. 


Fig.  366. — A  Large  Raw  Area  Leii  .Vftkr  Re- 
moval OF  a  Cystic  Mvoma. 

Gyn.  No.  4828.  The  abdomen  was  filled  with 
a  cystic  myoma  which  had  carried  (he  siRinoid 
Uexure  above  the  umbilicus.  The  sigmoid,  as  now 
seen,  has  dropjied  back  into  the  pelvis. 

In  closing  such  a  raw  area  the  large  vessels 
or  the  left  ureter  might  bo  very  easily  prickeil 
with  the  needle. 


620 


.MVO.MATA    OF    THK    UTERUS. 


^^^^en  the  bleeding  area  is  small  ami  the  needle  prick  causes  much  oozing,  the 
])()iiit  may  be  lifted  up  and  tied,  as  indicated  in  Fig.  367. 

A  large  raw  area  in  Case  7064  was  completel}'  covered  in  by  drawing  the 
broad  hgament  over  it.  The  l)ladder  may  also  be  pressed  into  a  similar  service, 
especially  where,  as  a  resuh  of  an  extensive  myomectomy,  the  surface  of  the 
uterus  is  much  roughened.  In  some  of  these  cases  we  have  drawn  the  bladder 
over  such  an  area  and  sutured  it,  thus  completely  hiding  the  suture  line.  Oc- 
casionally we  have  drawn  the  bladder  peritoneum  back,  and  attached  it  to  the 
peritoneum  of  the  rectum. 

In  suturing  the  peritoneum  (Fig.  366)  delicate  needles  and  fine  catgut  should 
be  employed,  and  great  care  exercised  to  avoid  piercing  blood-vessels  or  one  or 
other  ureter. 

Where  thickened  and  indurated  areas  are  felt,  as  after  the  evacuation  of  a 
[X'lvic  abscess,  it  is  not  only  impossible,  but  unwise, 
to  attempt  to  cover  them  over  with  peritoneum.  In 
such  cases  a  gauze  drain  laid  in  the  pelvis  and  brought 
out  through  the  vagina  will  yield  the  best  results. 

Irrigation  of  the  Abdominal  Cavity. — In  many  of 
the  myoma  cases  operated  upon  in  the  early  days  of 
the  hospital  the  abdomen  was  irrigated  with  salt  sol- 
ution just  prior  to  closure.  Sometimes  this  was  done 
to  wash  out  any  blood  that  might  have  escaped  into 
the  abdominal  cavity;  in  other  cases  to  cleanse  the 
intestines  when  i)us  had  escaped  during  the  hyster- 
ectomy. 

With  our  more  careful  technic  in  walling  off  the 
tumor  from  the  general  cavity  with  gauze,  the  abdom- 
inal contents  are  rarely  soiled,  and  if  contaminated, 
they  are  carefully  wiped  off  with  gauze  slightly  moist- 
ened  with  salt  solution.     When  it  is  impossible  to 
cleanse  the  pelvis,  the  infected  area  is  lightly  packed  with  gauze,  the  low^r  end  of 
wiiich  is  brought  down  into  the  vagina.     The  patient  is  then  put  to  bed,  and  is 
kept  in  Fowier's  position  for  several  days. 

She  is  permitted  to  drink  all  the  water  she  desires  from  the  moment  she 
recovers  from  the  anesthetic. 

We  have  entirely  given  up  abdominal  irrigations  after  hysterectomies  for 
myomata. 

Hemorrhage  During  Abdominal  Hysteromyomectomy. — When  the  uterus  is 
small  and  uniform,  the  ovarian  and  uterine  vessels  are  easily  gotten  at  and 
controlled ;  but  when  the  tumor  has  reached  large  proportions,  not  only  are  the 
vessels  displaced,  but  of  necessity  they  are  also  much  larger.  Sometimes  the 
uterine  artery  on  one  side  may  be  carried  up  into  the  abdomen,  wiiile  on  the 
opposite  side  it  is  deep  in  the  pelvis.     The  vessels  may  reach  tremendous  pro- 


FiG.  367. — Method  of  Controll- 
ing A  Bleeding  Are.\  W'here 
A  Needle  Cannot  be  Safely 
Employed. 

Sometimes  a  bleeding  point 
lies  directly  over  a  ureter  or  a  large 
vessel,  and  any  attempt  to  suture 
the  area  might  entail  injury  to  the 
vessel  from  the  point  of  the  needle. 
By  lifting  up  such  an  area  with  a 
pair  of  curved  forceps  the  operator 
can  effectually  control  the  bleed- 
ing without  using  the  needle. 


ABDOMIXAL    HYSTKROMYOMFX'TOMY 


621 


portions.  In  Case  7474,  for  example,  the  uterine  arteries  were  fully  as  lar-ic 
as  the  femorals.  A  corresponding  augmentation  in  the  diameters  of  the  veins 
has  also  been  noted. 

The  great  increase  in  the  size  of  the  ovarian  vessels  is  described  on  p.  352. 

Hemorrhage  from  the  Pedicle  of  a  Subperitoneal 
Myoma. — During  a  hysterectomy  nmch  traction  is  naturally  employed, 
and  sometimes  subperitoneal,  pedunculated  nodules  are  partially  or  completely 
pulled  away  from  the  uterus  (Fig.  368).  In  such  cases  free  hemorrhage  follows 
unless  the  pedicle  is  quickly  clamped.  This  condition  was  present  in  Case  II.. 
admitted  to  the  Church  Home  and  Infirmary,  ]\Iarcli  Ki,  1903. 

Hemorrhage  Due  to  General  Oozing.  W'licii  the  myoma- 
tous uterus  is  adherent  to  the  surrounding  structures,  free  hemorrhage  often 
accompanies  the  liberation  of  the  tumor.  This  is  due  chiefly  to  capillary  ooz- 
ing, and  not  to  bleeding  from  vessels  of  any  appreciable  size.  The  more  recent 
the  adhesions,  the  more  marked 
is  the  tendency  to  bleed.  — """^  ^ 

Tearing         of  the 

Ovarian  Vessels  . — In 
Case  7276,  during  the  release  of 
adhesions,  one  of  the  ovarian 
vessels  was  torn.  Free  hemor- 
rhage followed,  but  was  quickly 
controlled  with  forceps. 

In  Case  7064   the  hvsterec- 


FiG.  368. 


-Temporary  Control  of  Bleeding  fro.m  a  Sub- 
peritoneal Pedunculated  Myom.\. 
During  an  abdominal  hysteromyomectomy  a  subperitoneal 
myoma  may  be  partially  torn  away  from  the  uterus,  and  trouble- 
some oozing  follow.     If  the  operation  is  a  long  one,  a  mattress 
suture  will   effectually   check   the   bleeding.     iJ   is   a  side  view 
tomy    was    a    most  difhcult    one,        showing  the  suture  securely  tied. 

owing  to  dense  vascular  adhe- 
sions, and  because  the  tumor  so  accurate!}'  filled  the  jieKis.  The  v(>ssels  were 
clani])ed  as  eiicouiitei'ed  and  tieil  later.  The  right  oNarian  \-essels  were  tied  and 
the  clamps  reiiioN'ed.  Tiie  ligature  was  not  tight  enough,  the  artery  retracted,  and 
the  free  bleeding  innnediately  jiroduced  a  wide-s])read  heni.-itoma,  obscuring  the 
situation  of  the  artery.  It  was  necessary  to  tie  the  \-essel  high  al»o\'e  the  brim 
of  tlie  peh'is,  at  the  point  at  which  it  ci'ossed  the  lU'etei'.  The  hematoma  was 
then  shelled  out,  and  the  peritoneal  surfaces  were  approximated. 

Hemorrhage  from  tiie  ovarian  ves.^els  is  usually  a  minor  complication,  as  these 
vessels  are  easily  accessible. 

Hemorrhage  from  the  I'terine  \' e  s  s  e  1  s  .  In  ("ase()722, 
after  the  left  uterine  vessels  had  been  tieil  and  sexcreil.  the  ceixix  was  cut 
across.  Suddenly  the  right  uterine  artery  was  torn,  .and  thei-e  w;is  excessive 
and  almost  uncont  I'ollalile  bleeding  h)r  half  a  minute.  :ifter  which  the  ai'lei-y 
was  successfully  clampecl. 

The  myomatous  uterus  in  Case  Tl'tiii  w.as  densely  adhereiil  .and  wedged  in  the 
pelvis.  During  the  operation  the  let'l  uterine  arleiy  w.as  torn.  ;ind  free  hemor- 
rhage followed  before  it  could  be  controlleil. 


622  MYOMATA    OF   THE   UTERUS. 

After  tying  off  the  omental  adhesions  in  Case  6206  the  operator  deUvered 
the  myomatous  uterus  and  then  began  enucleation  on  the  left  side.  The  left 
ovarian  vessels  and  the  left  round  ligament  were  controlled  and  severed,  and  the 
bladder,  which  was  high  up  on  the  surface  of  the  tumor,  was  freed.  As  the  tumor 
was  being  pulled  up  to  get  at  the  left  uterine  artery,  this  vessel,  together  with 
several  large  veins,  was  suddenly  torn,  and  there  was  a  tremendous  gush  of 
blood.     The  bleeding  was,  however,  quickly  checked. 

During  removal  of  the  densely  adherent  myomatous  uterus  in  Case  11634 
the  left  uterine  artery  ruptured  at  a  point  just  external  to  the  ureter.  In  this 
ease,  on  account  of  the  oozing,  it  was  necessary  to  drain  through  the  vagina. 

During  removal  of  a  small  densely  adherent  myomatous  uterus  in  Case  7120 
the  uterine  artery  was  torn  while  the  bladder  was  being  liberated.  The  tear  was 
in  such  close  proximity  to  the  ureter  that  it  was  necessary  to  carefully  dissect 
out  the  ureter  to  avoid  injury  to  it.  The  artery  was  then  ligated  near  the  pelvic 
floor. 

Alarming  Hemorrhage  from  "\'  e  s  s  e  1  s  on  the  Pelvic 
Floor  . — In  Case  6792  the  uterus  was  found  perched  on  the  top  of  a  large 
myoma.  The  normal  appendages  on  each  side  and  both  round  ligaments  were 
tied  and  severed.  The  bladder  was  then  freed  and  pushed  dowTi,  and  the  uterine 
arteries  on  both  sides  were  controlled.  The  uterus  with  the  appendages  was 
then  removed.  The  tumor  was  then  shelled  out  of  the  loose  cellular  pelvic 
tissue.  It  came  out  easily,  but  with  tremendous  hemorrhage,  the  blood  almost 
filling  the  pehis.  After  much  difficulty  it  was  found  that  the  hemorrhage  came 
from  a  large  vessel  on  the  pelvic  floor.  This  was  ligated,  but  the  general  oozing 
was  still  so  profuse  that  the  anterior  branch  of  the  internal  iliac  artery  was  tied. 
The  raw  area  was  now  covered  in,  care  being  taken  not  to  injure  th(^  urc^ter, 
which  was  placed  toward  the  median  line. 

After  all  bleeding  had  ])ecn  checked,  several  gall-stones  were  removed.  The 
patient  left  the  hospital  well. 

The  myomatous  uterus  in  Case  6915  was  as  large  as  that  of  an  eight  months' 
pregnancy,  and  the  abdominal  walls  were  very  thick.  The  bladder  reached  al- 
most to  the  umbilicus. 

i'jiucleation  was  begun  from  right  to  left,  and  large  masses  of  ovarian 
vessels  were  raised  with  difficulty  and  tied  off,  in  a  narrow  space  between  the 
tumor  and  the  pelvic  brim.  After  section  of  the  round  ligament  the  bladder  was 
dissected  free  on  the  right  side  and  a  large  mass  of  knotted  veins  passing  from 
the  uterus  to  the  bladder  was  revealed.  These  were  ligated  and  cut.  The  right 
uterine  vessels  were  exposed  and  tied  without  difficulty;  the  cervix  was  cut 
across,  and  the  left  uterine  vessels  controlled.  As  the  uterus  was  being  care- 
fully drawn  up  there  was  a  sudden  uncontrollable  limiorrhage.  The  l)loe(Hng 
point  could  not  be  gotten  at,  and  nothing  remained  but  to  remove  the  uterus  with 
the  utmost  speed,  notwithstanding  the  bleeding.  The  tumor,  which  still  held 
by  its  ovarian  attachment,  was  rolled  out  of  the  abdomen,  the  l)lood  rai)idly 


abdo:mixal  hysteromyo.mectomy.  023 

ladled  out  of  the  pehis,  and  a  large  spurting  vessel  caught  on  the  jielvic  floor. 
During  the  necessarily  speedy  removal  of  the  uterus  the  hladdei-  was  torn  from 
the  trigonum  to  the  symphysis.  The  rent  was  closed,  and  the  ..pcrat  ion  (•(.iiii)l('t('d 
in  the  usual  way.     The  patient  was  discharged  well  on   the  thirty-third  day. 

Hemorrhage  Due  to  Slipping  of  a  Ligature  .—In  Case 
6178  the  ligature  around  the  left  uterine  artery  slipped  and  free  hemorrhage 
followed  for  several  minutes.     The  vessel  was  caught  and  retied. 

Just  as  the  abdomen  was  being  closed  in  Case  5734  free  blood  was  noted  in 
the  pelvis;  the  ligature  controlhng  the  left  uterine  artery  had  shj)j)ed.  The 
vessel  was  retied. 

Hematoma  in  the  Broad  Ligament  .—In  Case  5193.  at  the 
close  of  the  operation  a  hematoma,  4x5  cm.,  was  noted  in  the  left  Inroad  ligament. 
The  clot  was  turned  out  and  the  bleeding  vessels  were  controlled. 

Hematoma  Under  the  Sigmoid  Flexure  .—After  removal 
of  a  large  myomatous  uterus  in  Case  7583  a  hematoma,  3x5  cm.,  was  detected 
under  the  sigmoid  flexure.  It  was  opened  and  the  bleeding  ve.'^sels  were  con- 
trolled. 

Almost  Fatal  Bleeding  from  an  Accessory  Branch 
of  the  Uterine  Artery  .—The  myomatous  uterus  in  Case  4731  filled 
the  entire  lower  abdomen.  The  cervix  was  represented  as  a  mere  button. 
Abdominal  hysterectomy  was  performed  without  difficulty,  notwithstaiitiiiig 
intestinal  adhesions  and  the  marked  vascularity  of  the  tissues.  Just  as  tiie 
patient  was  ready  to  leave  the  table  she  became  pulseless  and  markedly  blanched ; 
a  large  clot  was  found  filling  the  vagina. 

On  account  of  the  collapse,  internal  hemorrhage  w^s  suspected,  and  the 
abdomen  was  at  once  explored.  No  blood  being  found,  the  cervical  stumj)  was 
reopened,  and  an  accessory  branch  of  the  uterine  ai'tery  found  spurting.  The 
blood  from  this  I'ouiul  its  way  into  the  vagina  through  the  cervical  canal.  Al- 
though the  patient  was  ])ulseless  at  the  wfist.  she  soon  rallied  and  left  ilir  hos- 
pital well  at  the  end  of  iWo  wec^ks. 

The  above  cases  yield  some  yvry  important  practical  suggestions: 

1.  In  cases  in  which  much  difficulty  is  exjx'cteil.  tie  vessels  and  cut  as  you 
go.  When  the  emergency  ai'ises,  the  field  will  not  lie  entirely  obstructed  by 
artery  forceps. 

2.  Doubly  ligate  all  the  caidinal  vessels. 

3.  If  a  hematoma  forms,  shell  it  out  and  catch  the  x'cssels. 

4.  Inspect  all  st umps  carefully  to  see  if  bleeding  has  been  effect nally  checked. 

5.  Whenever  there  is  dangei'  of  including  the  uretei-  in  a  ligature,  dissect  it 
out  to  be  sure  that  it  is  intact. 

6.  In  whi))])ing  over  the  pelvic  ))eritoneum  he  careful  not  to  puncture  a 
vessel,  as  a  hematoma  will  result. 

Vaginal  Drainage.  \\'hei'e,  on  account  of  I'.aw  areas  in  the  jichis  that  cannot 
be  satisfactorily  covered,  or  whei'e,  as  a  result   of  |)el\ic  infection,  it   is  deemed 


624 


MYOMATA    OF   THK    ITKRUS. 


advisable  to  drain  tlie  pelvis,  va^-inal  is  iialurally  |)refei-al)le  to  abdominal  drain- 
age. 

The  easiest  way  to  accomplish  this  is  to  liaNcaii  assistant  carry  a  pair  of  artery 
forceps  high  up   into   the  vagina.     The   operator   then   cuts   down   ui)on    the 

forceps  from  above  (Fig.  369).  The  opening 
thus  made  is  stretched  with  the  forceps,  the 
pelvis  is  quickly  wiped  out,  and  one  or  more 
long  pieces  of  iodoform  gauze  are  introduced. 
The  ends  of  the  gauze  are  grasped  with  the 
forceps  and  drawn  tlown  imtil  they  are  seen 
at  the  vaginal  outlet.  The  jx'lvic  portion  of 
the  drain  is  snugly  applied  to  the  raw  area, 
and  the  rectum  allowed  to  drop  down  over  it, 
so  that  no  small  bowel  can  become  adherent 
t(j  the  gauze.  A  ]Mece  of  rubber  tissue  around 
the  drains,  at  their  exit  from  the  pelvis,  will 
facilitate  their  removal  later. 

In  introducing  the  forceps  the  assistant 
must  push  them  up  directly  behind  the  cervix. 
If  introduced  to  one  or  other  side,  the  vessels 
of  the  broad  ligament  may  be  cut  or  the  ureter 
injured.  Sometimes  the  rectum  is  adherent 
to  the  postei'ior  surface  of  the  cervix.  Tn 
such  a  case,  if  it  is  not  previously  lil)erated, 
when  the  forcei)s  are  cut  down  upon,  the  in- 
cision will  first  open  uj)  a  fold  of  the  Ixnvel, 
and  then  the  vagina. 

The  artery  forcej)s  should  be  introduced 
into  the  vagina  under  sight.  In  one  case 
(C.  H.  I.,  949),  in  which  a  small  uterus  was 
studded  with  myomata,  a  pelvic  inflammation 
was  also  present.  On  account  of  the  pelvic 
inflammation  it  was  decided  to  drain  through 
the  vagina,  but  not  remove  the  uterus.  The 
assistant  experienced  much  difhculty  in  ])ush- 
ing  the  artery  forcej)s  up  into  the  vagina  direct- 
ly behind  the  cervix.  Finally,  however,  the 
maneuver  was  accomplished,  and  the  operator 
cut  down  upon  the  forceps  from  above.  He 
remarked  that  the  vagina  had  not  been  cai'efully  wiped  out .  as  a  small  amount  of 
clear  fluid  escaped.  After  two  ))ieces  of  3-inch  iodoform  gauze  had  been  laid  in  the 
pelvis  and  their  lower  ends  brought  out  below,  the  abdomen  was  closed.  To  our 
astonishment  the  end  of  the  gauze  was  found  emerging  from  the  urethra,  and  not 


Fig.  369. — Method  of  Establishing 
V.\GiN.\L  Drainage. 
Wlieii,  on  account  of  raw  areas  or 
continued  oozing,  it  is  deemed  advisable 
to  drain  the  pel\ns  through  the  vagina,  the 
latter  is  carefully  wiped  out  and  any  .secre- 
tions that  may  have  escaped  from  the 
uterus  during  operation  are  in  this  way 
removed.  A  long  curved  artery  forceps 
is  then  introduced  into  the  vagina  under 
sight,  and  pushed  up  directly  behind  the 
cervix,  as  indicated  by  a.  At  this  point 
the  forceps  is  cut  down  upon  and  then 
pushed  up  into  Douglas'  pouch.  The 
opening  is  then  enlarged  by  separating  the 
forceps  blades  or  with  a  dilator  from  above. 
The  ends  of  the  necessary  drain  or  drain.s 
are  now  caught  wth  the  forcejis  and 
drawn  down  into  the  vagina,  care  being 
exercised  not  to  include  the  rectum  or 
any  ligatures  in  the  forceps.  The  upper 
end  of  the  drain  is  held  taut  until  the  pelvi.s 
has  again  been  wiped  dry,  and  is  then  snugly 
api)lied  to  the  pelvis.  The  rectum  and 
bladder  usually  drop  down  and  completely 
cover  over  the  gauze,  eflfectually  preventing 
any  loops  of  small  bowel  from  adhering 
to  it. 


ABDOMINAL    HYSTEROMYO.MECTOMY.  (Vi') 

from  the  vagina.  Naturally,  the  assistant  had  had  much  difficuhy  in  bringing 
the  tip  of  the  forceps  up  behind  the  cervix,  but  hnally  had  done  .so  by  greatly 
stretching  and  distorting  the  bladder.  The  abdomen  was  at  once  opened,  the 
gauze  was  drawn  out  from  below,  and  a  complete  hy.sterectomy  performed, 
the  ureters  being  at  the  .same  time  carefully  dis.sected  out,  as  it  was  impo.ssil)Ie 
to  tell  whether  they  had  also  Ix'en  injured.  They  were  found  intact;  the  hole 
in  the  base  of  the  bladder  was  closed,  and  the  patient  made  a  perfect  recovery. 

A  similar  example  is  furnished  by  Case  ('.  IT.  T..  1552,  Decend^er  31,  1000. 
In  this  case,  after  removal  of  a  densely  adherent  ovaiian  cy.st,  an  artery  forceps 
was  introduced  from  l)elow  and  cut  down  u])()n  from  above.  Next  morning 
the  ends  of  the  two  pelvic  drains  were  found  emerging  from  the  rectum  instead 
of  from  the  vagina.  The  abdomen  was  at  once  opened,  and  the  drains  with- 
dra^^•n  from  the  rectum.  Only  with  great  difficulty  was  the  opening  in  the  l)oweI 
closed,  as  the  hole  in  the  rectal  nmco.sa  was  at  a  point  4  cm.  below  that  in  the 
outer  or  peritoneal  coat.  Finally,  we  reproduced  the  conditions  ])resent  when  the 
bowel  was  injured,  by  carrying  the  index-finger  of  the  left  hand  up  in  the  rectum 
to  the  hole,  and  then  pushing  it  up  until  it  was  opposite  the  hole  in  the  peri- 
toneum. The  opening  was  thus  closed  from  above,  and  a  drain  introduced. 
The  pati(Mit  Tnade  an  uninterrupted  recovery. 

Successful  Hysterectomy  in  a  Constitutional  Bleeder. — In  (  ase  1 1019  the  patient 
was  forty-seven  years  old.  She  gave  a  history  of  nejihi-itis.  was  weak  and 
anemic,  and  had  a  hemoglobin  of  40  per  cent.  Ever  since  a  chikl  she  had  bled 
profusely  from  the  slightest  scratch  or  cut.  Her  sisters  also  had  a  marked  pre- 
disposition to  hemorrhage.  She  entered  the  hospital  on  account  of  a  myomatous 
uterus,  which  reached  to  the  umbilicus.  There  was  severe  utei-ine  bleeding. 
After  her  hemoglobin  had  risen  to  60  per  cent,  hvsterectomy  was  performed, 
and  the  patient  made  a  good  recovery.  The  tendency  to  bleeding  in  no  way 
retarded  her  convalescence. 

Abdominal  Hysterectomy  in  a  Syphilitic  Patient. — In  Case  ()791  a  woman, 
aged  forty,  was  the  mother  of  two  children.  She  had  had  .syphilis  for  several 
years.  On  admi.ssion  .she  was  very  weak,  and  had  a  .soft  .systolic  murmur  al  the 
apex. 

The  myomatous  uterus  was  removed  thi'ough  the  abdomen.  The  rr- 
moN'al  was  rendered  difficult  on  account  of  chronically  inflamed  and  adherent 
adnexa  and  dense  vesical,  intestinal,  and  ai)pendiculai-  .ulhesions.  .Not wit h- 
.standing  these  complications,  the  luetic  taint  did  not  .-ipp.arently  retard  the 
]iati(>nt's  |)i'()gi'ess  and  she  made  a  good  i'eco\'ery. 

Hysteromyomectomy  in  Patients  with  Renal  Lesions.  WC  shall  here  discuss 
only  those  cases  in  which  ihe  jjatients  i-ecovei'ed.  'i'he  othei's  ai'e  dealt  with 
in  e.iienso  in  their  appropi'iate  chaplers. 

In  Ca.ses  10()9,  13<S;>.^,  and  1()7l'.  aliiumin  without  casts  was  iiotnl  licfore 
operation.     After  removal  of  the  uleius  the  ;ill>uniin  disajjpeared. 

In  Case  1946  albumin  was  noted  before  opera  lion.      I  m  media  ti'ly  alter  remoxal 
40 


026  MYOMATA    OF    TIIK    I  TFJUS. 

of  the  uterus  it  incivascd  in  amount  aiul  then  disappcaivd.  In  these  cases  we 
cannot  say  definitely  that  the  kichieys  were  chseased,  hut  the  albumin  certainly 
indicated  an  abnormal  condition. 

When  a  hysterectomy  is  comem])lated  and  the  urine  found  to  contain  al- 
bmiiin  and  casts,  we  have  to  consider  whether  the  patient  can  successfully 
withstand  the  ojx'ration.  It  is  a  well-known  fact  that  any  patient  having  neph- 
ritis has  a  lowered  resistance,  and  that  the  dangers  accom])anying  any  o{)eration 
are  much  inci-eased.  ( )n  the  other  hand,  the  local  ])eb-ic  condition  in  some  cases 
is  becoming  so  serious  that  the  patient  will  in  all  likelihood  succumb  if  operative 
relief  is  not  given. 

The  following  cases  show  what  may  be  accomplished:  In  Case  olO.S,  a  white 
woman,  aged  fifty-four,  had  for  foui'  years  been  losing  a  good  deal  of  blood. 
The  last  hemorrhage,  she  claimed,  amounted  to  two  or  three  quarts.  The  lower 
abdomen  was  filled  with  a  globular  uterus.  The  urine  contained  albumin  and 
casts.  After  an  abdominal  hysterectomy  tlie  urine  diminished  in  amount,  while 
the  albumin  increased  and  hyaline  and  granular  casts  were  very  abundant. 
Convalescence  was  otherwise  uneventful.  The  bleeding  was  due  to  a  sub- 
mucous myoma  6  cm.  in  dianu'ter. 

In  (a.se  ()272,  a  colored  woman,  age(l  thirty-six,  entered  Dr.  Osier's  service 
suffering  from  nephritis  and  mitral  insufficiency.  Later  she  was  transferred 
to  the  gynecological  department  on  account  of  a  myomatous  uterus.  When  the 
abdomen  was  opened,  a  considerable  amount  of  ascitic  fluid  was  found.  The 
nmltinodular  uterus  filled  the  lower  abdomen  and  was  firmly  fixed  in  the  pelvis. 
After  removal  of  the  uterus  the  appendix  was  amjuitated.  The  patient  recovered 
perfectly  from  the  operation,  and  was  returned  to  the  medical  side  for  further 
treatment. 

The.se  two  ca.ses  demonstrate  cletirly  that  much  may  be  accomplished  even 
in  most  unfavorable  subjects. 


General  Hints  in  Operations  for  the  Removal  of  Uterine  Myomata. 

The  following  procedures  we  have  found  of  especial  value.  l)efore,  during, 
and  after  hysteromyomectomy. 

Before  Op  e  rati  o  n  . — A\'hen  the  j)atient  is  very  anemic  we  build  her 
Uj)  with  rest,  good  food,  iron,  strychnin  and  ])lenty  of  fresh  air,  and  ojx'rate  before 
the  next  period,  if  this  is  likely  to  be  profuse. 

Inoperable  cases  may  later  h(>come  operable. 

Remember  that   almost   moi'ibund  patients  may  recover  if  operated  u])on. 

Never  operate  without  full  pei-mission  to  do  all  that  is  necessary,  and  then 
be  as  conservative  as  possible. 

Never  tell  the  ])atient  that  there  is  no  danger  in  the  operation. 

Have  the  bowels  well  emptied  befoi-e  operation. 


ABDU.MIXAL    HYSTERO:\I YOMECTOM Y,  ■  ()27 

During  Operation  . — Always  determine  the  upper  limit  of  the  bladder 
with  the  cathetcn-  before  opening  the  abdomen. 

When  a  pelvic  abscess  exists,  drain  through  the  vagina  and  do  a  hysterectomy, 
if  necessary,  two  or  three  months  later. 

A  good  long  abdominal  incision  saves  time  in  the  end.  Cut  down  almost  to  the 
symphj^sis. 

Employ  the  operation  offering  the  quickest  and  easiest  removal  of  the  uterus, 
and  involving  the  least  danger  of  loss  of  blood  and  of  infection. 

A  tumor  wedged  in  the  pelvis  can  sometimes  be  pushed  up  by  the  hand  in 
the  vagina. 

Rotate  or  "lateralize"  a  tumor  to  facilitate  its  delivery  from  the  abdomen. 
A  corkscrew  introduced  into  the  tumor  answers  as  a  good  tractor  in  some 
cases,  but  should  not  be  used  where  malignancy  is  suspected. 

Get  at  dense  adhesions  from  the  under  surface  if  possible. 

Where  dense  intestinal  adhesions  are  present,  sacrifice  the  outer  coats  of  the 
tumor  (Fig.  377,  p.  635).     Do  not  injure  the  bowel. 

When  large  omental  vessels  enter  a  myoma,  ligate  and  tie  distally  and 
proximally.     These  vessels  are  very  friable,  and  may  tear  if  clamped. 

The  ovarian  and  uterine  vessels  in  difficult  cases  may  be  more  easily  exposed 
by  rotating  the  uterus. 

Treat  the  cervical  canal  as  if  it  were  an  infected  area. 

When  the  tumor  involves  the  cervix,  do  a  complete  hysterectomy. 

Cover  in  all  raw  areas  when  feasible. 

If  a  large  raw  area  involves  several  inches  of  small  bowel,  short  circuit  by 
means  of  a  lateral  anastomosis,  and  then  roll  in  the  raw  area  (Fig.  378,  p.  635). 

After-treatment  . — Give  enough  morphin  to  relieve  pain  during 
the  first  twenty-four  hours. 

Let  the  patient  (h'iiik  all  the  water  she  desires  from  the  time  of  operation, 
provided  there  are  no  especial  contraindications.  If  she  vomits,  the  stomach 
will  be  thoroughly  washed  out.  If  she  retains  the  water,  the  excess  of  mucus 
will  be  carried  into  the  bowel. 

Get  the  patient  on  the  back-rest  in  two  or  thnn'  days  after  operation,  if 
feasible. 

Use  little  catharsis — rely  chiefiy  on  enemata. 

If  there  is  the  slightest  sign  of  intestinal  obstruction,  give  no  cathartic  l)y 
mouth,  as  it  may  increase  tiie  kink.  Coax  the  intestinal  contents  down  with 
enemata. 

Alow  enema  of  two  ounces  each  of  glycei'in  ami  watei'  will  almost  inxariably 
relieve  abdominal  distention  if  not  due  to  obstruction. 

Open  the  abdomen  at  once  if  thei'e  are  dehnile  signs  of  jx-ritonitis  or 
obstruction. 


628 


MYOMATA    OF    THK    UTERUS. 


Ome  nt  um/ 


Bladder-  attachment 


Fit;.  370. — An  Indication  van  Ahhominai.  I.\sTK.\r)  oi-  \'a(iinm.  H  vstkuomvomkctom  v.  (J?  nat.  size.) 
Path.  No.  1990.  Some  suiKeoiis  aiivocule  vaginal  removal  of  the  msomatims  uterus  as  a  routine  procedure, 
but  in  our  experience  the  enlarged  uterus  is  often  adherent  to  the  omentum  or  to  the  bowel,  and  removal  from 
below  would  prove  a  hazardous  procedure.  In  this  case  we  have  a  large  left  pus-tube  which  did  not  lie  in  the 
pelvis,  but  high  in  the  abdomen.  Its  removal  from  below,  even  in  the  absence  of  the  large  myoma  in  the 
left  broad  ligament,  would  have  been  fraught  with  grave  danger.  As  we  are  never  absolutely  sure  what  we  will 
find  on  exploring  the  abdomen  in  these  cases,  it  certainly  seems  that  aljdominal  hysteromyomectomy  is,  as  a  rule, 
the  more  surgical  procedure. 


ABDOMINAL    HYSTEROMYOMECTOMY,  629 

Vaginal  Hysteromyomectomy. 

Vaginal  removal  of  the  uterus  is  easily  carried  out  provided  the  myomata 
are  fe\Y  in  number  and  of  small  size,  and  provided  there  is  a  certain  amount  of 
prolapsus. 

In  about  one-half  of  the  cases  the  appendages  were  adherent  (see  p.  337) 
the  adhesions  adding  materially  to  the  difhculty  of  removal  through  the  vagina. 

The  uterus  may  be  removed  intact  by  the  usual  method;  Init,  if  too  large, 
may  be  drawn  down,  l)isected,  and  removed,  as  has  l)een  so  brilliantly  done  bv 
Doderlein,  Segond,  Kronig,  Wertheim,  and  others. 

Our  findings  at  operation  have  only  served  to  strengthen  our  opinion  that 
when  the  uterine  myomata  are  of  sufficient  size  to  cause  trouble,  it  is  wiser  to  re- 
move the  uterus  from  above,  especially  as  in  some  instances  there  are  other  and 
unsuspected  pathologic  conditions  in  the  abdomen  reciuiring  treatment  (Fig. 
370),  lesions  that  might  be  totally  overlooked  unless  the  abdomen  were  opened. 

We  must  admit  that  the  recovery  after  vaginal  hysterectomy  is  a  more 
speedy  one,  and  that  the  immediate  discomforts  are  infinitely  less,  but  in  the  end 
we  feel  that  the  patient's  condition  is  much  better  after  the  abdominal  operation. 

Out  of  the  total  of  993  hysteromyomectomies  only  24  were  by  the  vaginal 
route. 


CIIAPTl-li   XXXII. 

DIFFICULT  ABDOMINAL  HYSTERECTOMIES. 

Thick  Abdominal  Walls.  The  thickness  of  the  alxloiniiial  wall  plays  an  iin- 
j)()i-tant  rule  in  all  dilHcult  abdominal  operations  for  niyoiiiata.  If  the  walls 
are  thin  ami  lax,  exposure  of  the  abdominal  contents  is  easy,  but.  when  much 
adipose  tissue  is  )iresent,  removal  of  th(>  uterus  is  often  frau<2;ht  with  the  greatest 
difficulty.  The  thickened  abdominal  walls  naturally  increase  the  distance  to  the 
jx'lvis.  and  in  these  cases  there  is  liable  to  be  much  subperitoneal  ix'lvic  fat,  and 
also  much  fat  in  the  omentum.     Moi-eover,  these  patients  usually  breathe  l)adly. 


Fig  372. — An  I.vc.\rcerated  Myomatous  Uterus. 
Gyn.  No.  3119.  The  pressure  symptoms  were  so 
severe  just  prior  to  operation  that  the  patient,  aged 
thirty-four,  could  not  work.  In  order  to  get  at  the  cardi- 
nal vessels  and  to  deliver  the  tumor  it  was  necessary  to 
have  an  a.ssistant  press  up  from  below.  Even  then  de- 
livery of  the  uterus  would  have  been  exceedingly  difficult 
had  not  one  of  the  myomata  been  soft  as  the  result  of 
degeneration. 


Fig.  371.— .-V  Myo.matous  Uterus  Accu- 
rately Filling  the  Pelvis. 
Gyn.  No.  33.38.  The  enlargement  was 
due  to  a  myoma  in  the  posterior  wall.  If 
the  myoma  is  soft,  as  in  this  case,  the  car- 
dinal vessels  are  easily  controlled,  but  when 
the  tumor  is  very  dense,  it  may  be  impossible 
to  reach  the  ovarian  or  uterine  arteries. 
In  the  latter  case  myomectomy,  with  subse- 
quent hysterectomy  or  bisection,  would  have 
to  be  resorted  to.  This  uterus  could  not  be 
dislodged  from  the  jielvis  jjrior  to  ojjeration. 

The  amount  of  adipose  tissue  may  be  marked.  Thus  in  Case  271.3  the  ab- 
<loniinal  walls  were  (5  cm.  in  thickness. 

Uterine  Myomata  Adherent  to  the  Abdominal  Wall.  When  the  myomata 
are  undergoing-  sujipui'ation.  they  natui-ally  become  adherent  to  the  sui-roundino 
structures,  and,  if  near  the  abdominal  wall,  the  nodule  may  become  tlensely 
adherent  to  the  peritoneum    of  the  lateral    or  anterior   wall,  as    was  pointed 

630 


DIFF^ICFLT    ABDOMINAL    HYSTKUECTOMIF.S. 


631 


out  in  Chapter  IX.  Pelvic  adhesions  are  veiy  fre(|ueiit.  If  the  inflaniniatoi-v 
reaction  has  been  marked,  adhesions  between  the  abdominal  wall  and  the 
mj^oma  will  be  found  in  a  few  eases.  In  the  following  cases,  in  which  the  my- 
oma had  not  undergone  suppuration,  adhesions  to  the  abdominal  wall  were 
noted— Gyn.  Nos.  2091,  3440,  4870,  7237,  7739,  and  San.  No.  1049. 

Raw  areas  on  the  alxlominal  peritoneum  naturally  cause  the  surgeon  much 
concern.     His  aim  is  to  draw  over  the  peritoneum  and  complete!}^  cover  them, 
but  if  the  process  has  been  a  recent  one,  there  is  liable  to  be  considerable  indu- 
ration, and  the  peritoneum  is  brittle  in- 
stead of  elastic  and  pliable.     In   such  a 
case  it  is  almost  imj)ossible  satisfactorily 
to  eliminate  the  formation  of  intestinal  ad- 
hesions at  these  ])oints. 

Myomata  Snugly  Filling  the  Pelvis. — 
Fig.  371  represents  the  type  of  a  myoma 
that  is  often  difficult  to  remove.  It  fills 
the  pelvis  snugly  and  cannot  be  dislodged 
upward  into  the  abdominal  cavity.  Con- 
trol of  one  or  other  uterine  vessel  is  diffi- 
cult, but  when  one  side  has  l^een  tied  and 
cut,  the  cervix  can  be  cut  across  and  the 
tumor  rolled  out.  If  this  plan  is  not  feas- 
ible, it  may  become  necessary  to  shell  out 
the  large  tumor  and  do  a  hysterectomy,  or 
bisection  may  be  resorted  to. 

In  Fig.  372  we  have  a  very  large  un- 
n-ieldv  tumor,  which  not  onlv  completely     ''"*^"'''  ^'''^T  '^^  '''^'''^*"'  '"^fl«'^*'°"  f^''^^^^'^  *" 

"  ^  I  ,7         the  surface  of  the  tumor,  far  above  the  level  of 

fills  the  lower  abdomen,  but  also  the  pel- 
vis. In  such  a  case  shelling  out  of  the 
myoma  or  bisection  is  out  of  the  question. 
The  only  chance  of  removing  the  uterus 
lies  in  so  rotating  the  tumor  that  the  uter- 
ine vessels  on  one  side  can  be  controlled. 
The  cervix  is  then  cut  across  and  the  uttMuis  removed. 

Fig.  373  shows  a  rather  unusual  conditioii.  The  chief  myomatous  develoj)- 
ment  having  taken  })lace  between  the  folds  of  the  broad  ligaiiieiit.  it  has  become 
necessary  to  split  the  broad  ligament  on  each  side  and  carefully  stii])  it  off. 
Moreover,  when  the  iiiyoiuata  develop  in  sncli  a  niannei',  the  mctei-s  mav  be 
displaced  foi'ward,  ontwai'd,  or  down \\a I'd,  and  I  lieii-  local  ion  n nisi  be  ascerlaiiied 
most  carefnll)-.  In  this  case  llie  lunioi-  was  loosely  adlieivni  io  ihe  bladdei-  and 
rectum. 

Fig.  374  represents  one  of  the  most  dillicnlt  cases  the  surgeon  can  eiicounlei-. 
The  operation  was  begun  from  '■  right  to  left."'  Large  ma.sses  of  ovarian  veins 
having  been  with  dillicully  lied  and  cut,  ami  the  bladdei-  freed  bv  dissection 


Fig.  .37-3. — Retroperitoneal  Development  of 
Myomata. 
Gyn.  No.  4097.  The  myomatous  uterus 
reached  above  the  brim.  The  greater  part  of 
the  myomatous  development  had  been  retroperi- 
toneal. The  rectal  peritoneal  reflection  passed 
over  to  the  myoma  at  the  pelvic  brim.     Over  the 


the  symphysis.  Both  the  bladder  and  the  rec- 
tum were  displaced  high  into  the  abdomen,  and 
during  the  liberation  of  the  rectum  a  tear,  2  cm. 
broad  antl  12  cm.  long,  was  matle  in  its  outer 
coats. 

In  such  a  case  there  is  great  danger  of  injur- 
ing the  ureters,  which,  as  might  besui)posed, 
are  displaced  by  the  tumor. 


632 


MYO.MATA    OF    THK    UTERUS. 


a  large  mass  of  knotted  veins  was  revealed  passing  from  the  bladder  to  the  uterus. 
All  these  were  tied,  and  the  right  uterine  vessels  were  then  exposed  and  ligated 
with  nnioh  diffleulty.  The  cervix  was  cut  across.  The  uterus  was  drawn  up 
carefuUv.  hut  a  sudden  and  uncontrollable  hemorrhage  immediately  followed. 


Ov.  -\  essels 


Fig.  374. — .\.  Vkry   Difficult  H^sihiomiomi  <  i(>\n         '_  iiat.  size.) 
Gyn.  No.  691.5.     Path.  No.  3170.     The  body  of  the  uterus  reached   the  level  of  the  umbilicus  and  lay  sur- 
rounded by  myomatous  nodules.     The  bladder  had  been  drawn  upward  almost  to  the  umbilicus.     The  letters 
a  indicate  the  limits  of  the  peritoneal  covering  of  the  tumor. 

It  now  became  necessary  to  enucleate  with  the  utmost  speed.  The  tumor  was 
liberated  on  the  left  side  and  shelled  out.  Bh)od  was  literally  ladled  out  of 
the  pelvis,  and  all  spurting  vessels  were  caught.  The  tumor  was  cut  away  en- 
tirely and  removed.  The  bladder  was  torn  from  the  trigonum  to  the  symphysis 
and  drawn  out  in  a  long  thin  fhij).      It   was  sutured,  and  the  raw  pelvic  areas 


DIFFICULT    ABDOMINAL    HYSTKIIKCTOMIES. 


633 


were  covered  over.  Apart  from  a  mild  phlebitis  in  the  left  le<z;  on  the  twenty- 
third  day,  the  patient  made  a  jx'rfect  recovery.  If  the  uterus  had  not  been  re- 
moved with  the  utmost  speed,  the  patient  in  a  few  minutes  would  have  bled  to 
death  on  the  table. 

In  Fig.  375  the  myomatous  uterus  accurately  fills  the  pelvis  and.  viewed 
from  the  abdominal  incision,  would  seem  difficult  of  removal.  A  j^revious  care- 
ful bimanual  examination,  however,  would  hav(>  demonstrated  that  the  uterus 


Fig.  375. — A  Myomatous  UTKiiua  Blockixg  the  Pelvis. 
Autopsy  specimen,  January  15,  1897.     The  uterus  fills  the  pelvis  snugly  and  has  ciowdeil  the  greater  part  of 
the  bladder  above  the  symphysis.     Viewed  from  the  abdominal  cavity,  it  seems  almost  impossible  to  lift  the  uterus 
out  of  the  pelvis,  but  from  Fig.  .376  we  see  that  it  could  be  readily    dislodged  either  liy    upward   pressure   from 
below  or  by  means  of  a  corkscrew  from  above.      (After  Howard  A.  Kelly.) 

could  be  readily  dislodged  into  the  abdomen  (Fig.  376),  and  myomectomy  or 
hysterectomy,  according  to  the  age  of  the  patient,  rai)idly  carried  out. 

Intestinal  Adhesions.  \\  lieii  we  consider  in  how  many  castas  the  apjx'ndages 
are  adherent  (see  p.  337)  and,  referring  to  the  ehaplers  dealing  with  parasitic 
myoma  and  sui)purating  myomata,  follow  the  details  of  those  cas(\s  in  which  the 
myomata  were  densely  adherent  to  the  I'ectum,  or  wher(>  hyst(M'ectoiii\-  was 
rendered  exceedingly  dinicult  on  account  of  the  uterus  being  bound  down,  we  can 
readily  understand  why  intestinal  adhesions  are  commonly  found. ''= 

*  Proiioiiiiced  iiitcstiiKil  udlicsioiis  were  notctl  in  the  t'ollowing  cases:  (iyn.  No.  ,'Ao,  1151, 
2108,  2691,  ;«94,  ;W12,  3921,  4370,  4731,  4732,  4S7(),  4917,  r)123,  "V2(i0,  ■)392,  6133,  6324.  6432, 
6521,6791,70(>4,71Sl,7226,7."')t9,.SO()S,9()27.9O7S.9312.9(i7S.9736.  KM;.")!,  II  172,  12209.  t2lSS. 


684 


MYOMATA    OF   THK    VTERVS. 


The  bowel  may  become  adherent  to  th(>  myomatous  uterus,  to  one  or  both 
ap])emlages,  or  to  the  abdominal  wall;  or,  as  a  result  of  a  general  peritoneal 
infection,  the  intestinal  loops  may  become  adherent  to  one  another. 

If  the  peritonitis  has  been  of  recent  date,  tiie  involved  intestinal  looj^s  are 
much  injected,  freiiuently  edematous,  and  are  easily  parted,  but  their  separation 
is  followed  by  very  jjrofuse  bleeding  from  capillary  oozing. 

Where  the  intestines  have  been  long  adherent,  if  loosely  attached  ])y  fan-hke 
adhesions,  these  can  be  I'cadily  cut  without  any  hemorrhage.     Tn  some  instances, 


Fig.  376. — A  Myomatous  Uterus  that  Tk.nded  to  Sag  Down  a.nd  Completely  Fill  the  Pelvis. 
Autopsy,  January  15,  1897.     For  the  uterus  before  being  dislodged  from  the  pelvis  see  Fig.  375.     (After  Howard 

A.  Kelly.) 


however,  the  intestine  is  so  glueil  to  the  tumor  that  it  is  necessary  literally  to  cut 
it  away.  In  such  a  case  the  wiser  i)rocedure  is  carefully  to  dissect  through  the 
outer  layers  of  the  tumor,  leaving  them  attached  to  the  intact  bowel  (Fig.  377). 
AMien  a  large  raw  area  is  left  on  the  intestine,  it  is  usually  advisable  to  short- 
circuit  the  gut  just  l)cyoiid  and  turn  the  raw  areas  in  upon  themselves,  as 
indicated  in  Fig.  378.  The  treatment  necessary  when  supi)urating  myomata 
oj)en  into  the  bow'el  is  de.scribed  on  p.  612. 


DIFFICULT    ABDOMINAL    HYSTKRKCT(  )MIKS. 


635 


the 


on 


Myomatous  Uteri  Associated  with  Pelvic  Abscess. — In  .sonic  of  the  cases 
operator  can  definitely  outline  the  myomatous  uterus  from  above,  while 
vaginal  examination  induration 
of  the  vault  can  be  detected. 
This  board-like  thickening  can 
usually  be  readily  distinguished 
from  the  globular  bulging  of  a 
myoma  in  Douglas'  sac.  When 
such  an  induration  is  present, 
hysterectomy  is  for  the  time 
being  contraindicated.  An  in- 
cision should  be  made  behind 
the  cervix,  and  Douglas'  pouch 
drained.  Usually  the  patient 
will  improve  rapidly,  and  the  fig.  377.- 
vaginal  tissue  .soften  materially. 
She  may  be  sent  home  for  a  few 
months,  and  then  return  for  the 
hysterectomy.  It  is  astonishing 
to  note  how  much  the  nodular 
uterus  loo.sens  up  as  a  result  of  the  drainage,  and  wluit  would  have  been  a  for 
midable  and  dangerous  operation  now  becomes  relatively  easy.  The  following 
case  illustrates  .such  a  plan  of  treatment. 


Leaving  the  Outer  Layers  of  the  Myom.a  At- 
tached TO  the  Bowel. 
In  some  cases  when  the  bowel  is  densely  adherent  to  the 
myoma,  as  at  A,  the  outer  layers  of  the  tumor  can  be  left 
attached  to  the  intestine,  as  indicated  by  the  dotted  line  a-h. 
The  freed  bowel  then  presents  the  picture  B.  The  bowel-wall 
is  thus  preserved  intact,  and  the  lumen  is  encroached  upon 
only  .ilightly. 


Fig.  378. — Method  of  Dealing  with  Extensive  Intestinal  Adhesions. 
A  indicates  three  raw  areas — points  at  which  the  bowel  has  been  ailherent  to  the  myoma.  To  c 
in  successfully  necessitates  much  narrowing  of  the  lumen  of  the  bowel,  with  the  danger  of  postoperativ 
tion.  One  of  us  (Cullen)  in  such  Ciuses  does  a  lateral  amistomosis  as  a  routine  j)roceilure  In  Fig.  u, 
line  of  the  anastomosis  is  indicated.  The  raw  areas  of  the  bowel  are  then  turned  in  upon  ihemsclves, 
perfectly  smooth,  tongue-shaped  i>rojection,  c.     The  results  have  been  most  Katisfactor.\-. 


1'  r  (■  1  i  Ml  i  II  a  r  y     c  \'  a  c  u  a  t  i  o  11     o  f    a    |i  c  1  \'  i 
s  e  ({  u  e  n  t     h  y  s  t  e  r  o  111  y  o  111  c  c  t  o  in  y  . 


a  I)  s  ('  e  s  s  ; 


over  them 

e  obstruc- 

at  a,  the 

leaving  a 


ub- 


636 


MYOMATA    OF   THK    UTERUS. 


Mrs.  H.,  thirty-ciiilit  years  of  age,  was  adniittod  to  the  Church  Home  and 
Infinnary  on  March  :\\.  1<K)4.  She  had  for  a  lonji  time  comphiined  of  a  pain  in 
the  lower  abdomen.  Occupyinir  tlie  entire  lower  abdomen  was  a  hard  mass 
which  reached  almost  to  the  umbilicus.  Throu.uh  the  rectum  a  distinct  buljiin^-, 
irregular  in  character,  could  be  detected. 

On  opening  Douglas'  sac  through  the  vagina  we  encountered  a  smooth  jxx'ket, 
<»  cm.  in  diameter.  On  the  left  side  was  a  pus-cavity  containing  500  c.c.  of 
grayish-yellow,  non-odorous  ))us.  Both  cavities  were  drained.  The  patient 
left  the  hosi)ital  with  instructions  to  return  later  for  hysterectomy. 

July  26.  1004:  She  had  improved  greatly  in  health.  l)ut  the  i)ain  in  the  left 

side  had  been  ])ersistent.  On  opening  the 
abdomen  we  found  many  adhesions,  and  a 
myoma  (i  cm.  in  diameter.  The  right  tube 
and  ovary  wer(>  much  enlarged  and  densely 
adherent.  The  left  tube  and  ovary  formed 
a  mass  (S  cm.  in  diameter.  We  amj^utated 
from  right  to  left  with  nuich  difficulty,  but 
were  able  to  control  the  vessels  perfectly. 
\'aginal  drainage  was  employed,  and  the 
patient  made  a  good  recovery. 

While  it  is,  as  a  rule,  advisable  to  drain 
an   al:)scess   and  do  a  hysterectomy  later, 
Fig.  379.— a  Large  ag.scess  Lyi.ng  .a.ntekior     thcrc  are  ccrtaiu  cascs  ill  wliich  this  is  not 

TO  A  Myomatous  Uterus.  „         -i  ,  t       j^-       n-r\    f        •       j.  ii  i 

^      X-    onnc    Tu      .•    .        f  .  feasible.     In  hm'.  .^<0,  for  instance,  the  pel- 

Gyn.  !No.  8008.     The  patient  wa.s  forty-one  ' 

years  of  age   and    colored.     Three  weeks  before  vic  absCCSS   la\'  autel'lor  tO   tllC    UtcrUS,    aiul 

admission,  while  washing  clothes,  she  had  severe  -.i          .                i     i          •        i                  j.-                    i   i           j. 

pain  in  the  lower  abdomen,  an.l  on  the    follow-  WltllOUt   ail  alxlominal  OpCratlOll   COUld    HOt 

ing  day  noted    some    abdominal    swelling.     She  ]y^y(.    )jeen    illtelligeutlv    handled.        Ill    thlS 
was  in  bed  for  two  weeks  before  admission. 

At  operation  the  bia.i.ier  was  found  ex-     casc  it  was  wiscr  to  (lo  a  livsterectomy  at 

tending  half-way  to  the  umbilicus,  and  the  intes-  ,i  _  • 

tines    were    everywhere    adherent.     Anterior  to  L'te  .clllll     llIUl. 

the  globular  myomatoas  uterus  lay  the  large  ab-  fjjg     Treatment     Of     Apparently    InOpet- 

scess  indicated  by  the  shaded  area.     Both  tubes 

were  filled  with  clear  fluid.    Hysterectomy  was      able  Uterine  Myomata.— Great    diiiiculties 

perfonned    and  the  abscess  drained  through  the        .^^.^^  oCCasloUallv  eilCOUlltered   whcll     tile    ill- 
vagma.     Kecovery. 

testines  have  been  imperfectl}'  emptied,  or 
when  the  abdominal  organs  are  so  loaded  with  fat  that  exposure  of  the  field 
of  operation  is  almost  im])os.sible.  In  a  few  instances  the  pelvis  has  been  so 
deep  that  great  difficulties  were  exjn'rieiuHMl  in  removing  the  uterus. 

We  are  here  chiefly  interested  in  those  cases  in  which,  on  account  of  dense 
adhesions  or  the  coexistence  of  a  purulent  collection  in  the  pelvis,  hysterectomy  is 
almost  impossible. 

Case  71SI  is  an  example  of  that  class  of  cases  in  which  the  oijcrator,  on  (){)ening 
the  abdomen,  feels  almost  hopeless.  Everything  is  so  glue<l  down  and  covered 
with  adhesions  that  few,  if  any,  of  the  familiar  landmarks  are  visible.  Finally, 
he  finds  one  point  of  vantage,  and  after  loosening  up  this  area,  another  is  exposed, 
until  in  the  end  the  uterus  can  be  removed. 


DlFf^ICULT    ABDOMIXAL    HYSTERECTOMIES.  637 

Gyn.  No.  7181. 

A     (1  e  n  s  (>  1  y      a  d  h  0  r  e  11  t      111  y  o  111  a  t  o  u  s      u  terns. 

A.  II.  L.,  inaiTied,  white,  aged  forty-two.  Admitted  September  4;  dis- 
charged October  1,  1S99.  On  section  of  the  abdomen  the  omentum  was  found 
drawn  out  into  a  cord-hke  mass,  9  cm.  broad.  This  was  spread  out  over  the 
surface  of  the  tumor  and  had  become  adherent  to  the  bhidder.  The  tvinKjr  was 
wedged  in  the  pelvis  and  inmiobile;  a  nodule,  about  1 1  cm.  in  diameter,  extended 
upward  and  lay  against  the  right  costal  margin.  A  hand  was  j)assed  under  the 
mass,  and  by  rotation  the  nodule  was  brought  out  of  the  abdomen.  The  main  tumor 
mass  was  then  partially  raised  out  of  the  pelvis.  The  uterus  was  everywhere 
surrounded  by  adhesions,  and  posteriorly  no  opening  could  be  found  on  the  left 
side.  The  left  tube  and  ovary  were  densely  adherent  and  were  plastered  on  the 
side  of  the  tumor;  the  left  broad  ligament  lay  spread  out  over  the  surface. 
Posteriorly,  the  small  intestines  were  everywhere  densely  adherent  to  the  tumor. 
and  it  was  impossible  to  pass  a  hand  beneath  the  tumor  on  account  of  adhesions 
to  the  large  bowel. 

On  the  right  side  everything  was  glued  down.  The  ileum  and  a|)pendix  were 
adherent  to  the  infundibulopelvic  ligament.  The  right  broad  ligament  was  very 
much  thickened,  and  was  drawn  up  over  the  mass;  beneath  it,  in  the  angle  be- 
tween the  pelvic  wall  and  the  fundus,  was  a  small  cystic  tumor.  The  bladder 
was  drawn  high  up  over  the  tumor  and  covered  a  myomatous  nodule. 

Operation.  The  omentum  was  ligated  and  released,  the  small  gut  freed  along 
the  posterior  border.  The  left  tube  and  ovary  were  dissected  free  with  scissors. 
It  was  still  impossible  to  budge  the  tumor.  Finally,  an  opening  was  made  and 
the  ovarian  vessels  were  caught  about  3  cm.  above  and  under  the  sigmoid,  which 
also  had  to  be  dissected  back.  The  right  round  ligament  was  next  caught  and 
severed,  and  now,  for  the  first  time,  the  tumor  connnenced  to  yield.  The  bhidder 
was  most  carefully  outlined  and  j)ushed  down  with  a  sponge.  The  engorged 
left  uterine  artery  was  exposed,  caught,  and  ligated  with  heavy  silk.  Even 
then  the  tumor  was  so  immobile  and  so  densely  adherent  posteriorly  that  it 
was  deemed  best  to  control  the  vessels  on  the  right  side.  This  was  accomplished 
with  the  greatest  difhculty.  The  right  ovarian  \-essels  were  cont  rolled  after  the 
most  careful  dissection.  An  attempt  was  made  to  control  the  rigiu  uterine 
vessels,  but  they  could  not  be  exjiosed.  The  subvesical  vessels  were  large  and 
bled  a('ti\'ely.  The  cervix  was  amputated:  free  hemoiThage  l'olli)we(!,  but  llir 
right  uterine  vessels  were  then  caught  with  clamps  and  the  right  broad  ligament 
was  clamped  and  cut.  After  removal  of  the  uterus  the  light  tube  and  ovary 
were  gradually  dissected  loos(>.  The  reiiiaiiuler  of  the  opei-ali(tii  was  canied  out 
in  the  usual  maimer.     The  patient  made  a  x'ery  satisfactory  reco\-ery. 

C.  H.  I.,  Case  K.  March   14,   1903. 

r  t  e  r  i  II  e  m  y  o  m  a  t  a  a  s  s  o  c  i  a  t  e  d  w  i  l  h  a  n  o  \'  a  r  i  a  n  a  b  - 
s  c  e  s  s  ,     an     a  b  s  c  e  s  s     in      t  h  e     o  m  e  n  t  u  m     ( I''ig.     3<S0),     partial 


638 


MYOMATA    OF    THE    UTERUS. 


obstruction.      relict"      h  y      e  x  ])  1  o  r  a  t  o  r  y      o  p  c  rati  o  n  . 
H  y  s  t  e  r  c  c  t  o  111  y    two   w  c  v  k  s   1  a  t  c  r  . 

Case  K.,  seen  in  consultation  with  Dr.  A.  Harr  Snively,  of  Waynesboro,  Pa., 
on  March  14,  1903,  is  an  excellent  example  of  what  may  be  accomplished  by 
completing  the  operation  in  two  stages.  When  the  patient  Avas  first  seen,  there 
were  sym]itoiiis  of  obstruction.     These  were  relieved,  and  the  abdomen  was 


Fig.  380. — Circdmscribed  Abscess  in  the  Omentum  Associated  with  a  Densely  Adherent  Myomatous 

Uterus  and  an  Ovarian  Abscess. 
C.  H.  I.,  K.,  March  26,  1903.     The  uterus  reached  to  the  pelvic  brim.     In  the  longitudinal  section  of  the  uterus 
three  niyomata  are  seen.     It  also  contained  others.     Projecting  into  the  uterine  cavity  is  a  i)olyp.     The  posterior 
surface  of  the  uterus  is  densel.v  adherent  to  the  rectum.     One  ovarj-  had  been  converted  into  an  abscess  sac.     This 
is  not,  however,  visible  at  this  level.     The  omentum  is  markedly  thickened  and  contains  an  abscess. 

drained.  After  a  delay  of  nearly  two  weeks  it  was  possible  to  do  a  complete 
hysterectomy.  Had  we  attempted  a  radical  operation  when  the  patient  was  first 
seen,  she  would  have  undoubtedly  died  on  the  table. 

This  patient  had  been  ill  for  about  a  year,  and  several  months  before  had 
had  an  attack  of  pelvic  pain,  very  severe  in  character.  For  the  previous  two 
days  the  temperature  had  been  from  100°  to  101°  F.,  and  the  i)ulse  had  been 


DIFFICULT    ABDOMIXAL    HYSTERECT*  ).M1KS.  639 

rapid.  On  the  night  before  I  saw  her  she  colhijjsed,  and  her  jjulse  was  ahnost 
imper('e|)til)le.  .She  was  too  weak  to  be  removed  to  the  hospital,  and  ()j)eration 
was  imperative.  A  median  incision  was  made,  and  the  uterus  found  extending 
shghtly  above  the  pelvic  brim.  It  was  everywhere  wedged  in  the  pelvis  and 
covered  with  dense  adhesions.  Over  the  surface  of  the  tumor  the  omentum  and 
several  loops  of  small  bowel  had  grown  fast.  To  relie\-e  the  jiain,  we  loosened 
up  the  intestinal  loops  and  then  closed  the  abdomen. 

March  26,  1903:  The  uterus  contained  several  myomata;  both  tubes  were 
filled  with  pus  and  glued  to  the  pelvic  floor.  On  the  left  side  was  an  ovarian 
abscess  containing  a  considerable  quantity  of  very  fetid  pus.  Enucleation  was 
commenced  from  the  left  side,  and  was  found  to  be  impracticable.  The  right  side 
was  gradually  liberated,  the  uterus  cut  from  right  to  left,  and  also  pulled  away. 
The  walls  of  the  abscess  still  remained,  and  there  was  consideral)le  l)lee(ling  from 
the  peh'ic  floor.     A  pelvic  drain  ^^■as  carried  down  through  the  x'agina. 

Preparatory  to  closing  the  abdomen  we  carefully  examined  the  omentum  and 
found  that  it  contained  a  mass  about  10  cm.  in  diameter.  The  omentum  was 
very  hard,  and  the  condition  suggested  a  foreign  body.  In  order  that  there  might 
be  as  little  escape  of  pus  as  possible  we  incised  the  left  rectus,  continuing  the  in- 
cision five  inches  to  the  left.  The  omentum  w^as  tied  off  and  removed.  The 
thickening  was  found  to  be  due  to  an  isolated  omental  abscess  (Fig.  380).  At  one 
point  the  abscess  reached  the  peritoneum,  and  here,  over  an  area  1  x  2.5  cm., 
the  surface  had  become  necrotic.    The  patient  made  a  very  satisfactory  recovery. 

There  are  other  cases  in  which  the  operator,  once  he  has  commenced  the  oper- 
ation, from  the  character  of  the  condition,  is  forced  to  complete  it,  not  being  able 
to  abandon  it  at  any  stage.  One  patient  came  with  a  large  umbilical  hernia, 
densely  adherent  omentum,  and  a  large  myomatous  uterus  fllling  the  greater 
part  of  the  abdomen,  and  associated  with  a  large  ovarian  abscess  connnunicating 
with  the  bowel.  This  is  a  typical  example  of  such  a  group  of  cases.  This  pat  lent 
was,  fortunately,  in  good  condition,  and  made  an  excellent  recovery.  In  many 
of  these  cases,  however,  the  surgeon  is  in  a  quandary  as  to  what  should  be  done, 
realizing,  on  the  one  hand,  that  the  patient  is  continually  losing  ground,  ami.  on 
the  other,  that  operation  is  fraught  with  great  danger.  As  a  rule,  the  operation 
offers  the  only  j)()ssibility  of  relief. 

Gyn.  No.  5123.* 

Um  b  i  1  i  e  a  1  h  e  r  n  i  a  ;  m  u  1  t  i  n  o  d  u  I  a  i'  m  y  o  111  a  t  o  u  s  u  t  e  i'  u  s  ; 
large  o  v  a  r  i  a  11  a  b  s  c  e  s  s  c  o  m  111  u  n  i  eating  w  i  l  h  the  s  m  a  1  1 
bowel;    h  y  s  t  e  r  e  c  t  o  m  y  ;    r  e  c  o  v  e  i'  y  .     (Fig.  38 1 . ) 

R.  L.,  colored,  aged  forty.  Admitted  March  23,  1S97.  The  patieiil  had 
first  noticed  a  tuiiioi-  ten  years  before.  At  times  she  had  had  a  great  de;d  of 
abdominal  pain,  and  on  one  occasion  had  been  (•(inCnied  to  bed  tor  t  hree  months. 

*  Tlioinas  S.  Cullcn,  .Joliiis  Hi)i)kiiis  llos]).   Kuil.,  S.  IMtT.  \<>i.  \iii.  ]>.  '_M7. 


640 


MYOMATA    OF    THK    UTP:RUS. 


On  account  of  the  ii'r('<2;ul:ir  licrnial  jjrotrusion  th(>  nhdoininal  incision  was  com- 
menced at  a  point  midway  between  the  xi])h()i(l  and  the  unil)ihcus,  and  continued 
downward  to  within  a  short  distance  of  the  pulx's,  the  hernial  sac  being  encircled 
and  r(>ni()ved.  At  the  umbilicus  the  omentum  was  firmly  adherent.  Presenting 
at  the  incision  were  several  suhpei-itoiieal  iiiyomata.  To  these  the  omentum  was 
also  firmly  ailherent.  After  these  adhesions  had  been  loosened  up  the  nodular 
myomatous  uterus,  21  \  2S  em.,  was  delivered  (Fig.  381). 


Fig.  381. — A  Longitl-dinal  Skction  of  the  Abdomen  showing  an  Umhilical  Uernia,  a  Lakge,  Densely 
Adherent  Myomatous  Uterus,  and  an  Ovarian  Abscess. 
Gyn.  No.  .5123.  The  section  shows,  from  above  downward,  an  umbilical  hernia,  a  large  niultincMlular  myoma- 
tous uterus,  on  the  upper  and  anterior  surface  of  which  the  omentum  is  adherent,  a  pus-tube,  an<l  an  unusually 
large  ovarian  abscess,  which  communicated  with  a  loop  of  small  intestine.  The  abscess  was  more  on  the  right 
side  of  the  body,  but  has  been  drawn  on  the  same  level  to  bring  it  out  more  clearly.      (After  Thomas  S.  Cullen.) 


Occupying  the  posterior  pari  of  the  ])clvi(' cavily  was  an  elastic  tumor,  17  cm. 
in  diam(>ter.  This  looked  like  an  ovarian  cyst,  and  was  intimately  adherent 
to  two  loops  of  the  small  intestine.  I)iiriiii2;  an  attempt  to  shell  off  the  outer 
layers  of  the  cyst.  leaviii,ti  them  attached  to  the  intestine,  the  cyst  ruj)tured  and 
was  found  to  contain  about  <)()()  c.c.  of  grayish,  fetid  jnis.  After  removal  of  the 
uterus  the  ovarian  abscess  was  freed;  it  was  necessary,  however,  to  leave  a  small 
part  of  the  sac  attached  to  the  intestine,  and  on  careful  examination  an  opening. 


DIFFIdLT    ABDOMINAL    HYSTERECTOMIES.  641 

1  cm.  in  (liaiiictcr,  was  found  hctwccn  the  intestine  and  the  abscess  sac.  The 
margins  of  the  intestinal  opening  were  ahnost  as  dense  as  cartihige,  but  very 
friable.  After  a  good  deal  of  dissection  it  was  possible  to  turn  in  the  edges,  and  the 
opening  was  closed  with  fine  silk  sut  ures.  These  were  now  su])ported  with  a  second 
and  a  third  row.  Tlie  alxlomen  was  closed  without  drainage,  and  the  patient 
made  a  good  I'ecovery. 

The  Gradual  Absorption  of  Adhesions  after  Abdominal  Sections. — The  mere 
opt^ning  of  the  abdomen  is  in  some  cases  followed  by  |)artial  absorption  of  dense 
adhesions.  Case  W.  affords  a  striking  example  of  siicli  an  amelioration  of  the 
condition.  On  opening  the  abdomen  we  found  dense  adhesions  everywhere, 
and  the  operation  had  to  be  abandoned  at  once  on  account  of  the  patient's 
precarious  state.  She  gradually  inipnjved,  and  on  several  occasions,  in  the 
course  of  the  next  few  months,  she  was  brought  to  the  operating-room,  but 
each  time  to  no  avail.  Finally  we  were  alile  to  open  the  abdomen,  and  were 
greatly  surprised  to  note  how  the  tumor  had  loosened  up.  Hysterectomy  was 
performed,  and  the  patient  was  well  several  years  after.  In  this  case  she  would 
certainly  have  succumbed  on  the  table  had  we  attempted  a  radical  operation 
when  the  abdomen  was  first  opened. 

A.  W.     Path.  No.  8932. 

S  u  c  c  e  s  s  f  u  1  h  y  s  t  e  r  e  c  t  o  m  y  a  f  t  e  r  s  e  \'  e  r  a  1  u  n  s  u  c  c  e  s  s  - 
f  u  1     attempts. 

A.  W.,  aged  forty-five,  colored,  seen  in  consultation  with  Dr.  Brice  Golds- 
borough,  at  the  Cambridge,  Md.,  Hospital,  May  24,  1905.  For  four  years  her 
physician  had  been  endeavoring  to  have  her  submit  to  an  operation  for  a  large 
myoma,  but  she  had  persistently  refused.  When  I  saw  hei'  there  was  a  great 
deal  of  alxlominal  distention;  her  pulse  was  weak  and  i-apid.  The  history 
was  strongly  indicative  of  an  accom]Kuiying  peritonitis. 

On  o])ening  the  abdomen  we  found  what  ap])eared  to  l)e  a  lobuhited  myoma, 
everywhere  adherent  to  the  abdominal  wall  and  also  in  the  pelvis.  The  tumor 
bled  on  the  slightest  touch.  As  her  condition  was  desperate,  we  thought  it 
wiser  to  close  the  abdomen,  hoping  that  at  a  later  day  we  might  i-einove  the 
uterus. 

On  several  sul)se(|uent  occasions  she  was  bi'ouglit  to  the  opei-ating-room. 
but  as  soon  as  the  anesthetic  was  started  her  pulse  would  run  uj)  to  between  120 
and  150.  and  become  veiy  weak.  I'^inally,  on  August  17,  1!)05,  .she  was  again 
bi'ought  to  the  operating-i'ooiu.  Since  the  prex'ious  o])(Tation  she  had  impi'o\'ed 
markedly,  and  the  tuiiioi'  showed  much  mobility.  ( )ii  o])eiiiiig  I  he  abdomen  we 
foimd  we  wei'e  dealing  wit  li  a  multinodular  myomatous  uterus;  one  lai'ge  nodule, 
fully  II  cm.  in  diameter,  pi'esented  at  the  incision,  and  was  adherent  to  the 
abdominal  wall.  It  was  shelled  out,  claui])e(l,  and  reinoNcd.  .\  secoiul  nodule 
aj)peared  on  the  left  side.  It  was  treated  in  a  similar  maimei',  and  a  third  was 
removed  from  the  pelvis.  Durhig liberation  of  the  first  large  tumor  we  encountered 
41 


642  :myomata  of  tiik  uterus. 

an  abscess  which  lay  along  the  edge  of  and  in  a  cleft  of  the  tumor.  The  left  tube 
contained  a  quantity  of  milky  pus.  We  amputated  through  the  cervix,  removing 
the  entire  growth.  The  pelvis  was  tlrain(;d,  and  the  patient  made  a  slow  but 
iminterrui)ted  recovery,  and  in  the  course  of  a  few  months  was  able  to  resume 
her  work. 

The  histologic  examination  sliowed  that  the  abscess  cavity  noted  in  the  cleft 
of  the  large  myoma  was  lined  with  typical  granulation  tissue. 

February  20,  1907.     The  patient's  condition  is  excellent. 


CHAPTER  XXXIIT. 
PREGNANCY  AND  UTERINE  MYOMATA. 

In  the  cha])t(T  on  abdominal  niyonicctoiny  we  liave  considcnxl  those  cases 
in  which  a  niyonicctoniy  was  performed  (hirinij;  the  course  of  pregnancy,  and  on 
p.  528  we  have  given  data  rehitive  to  the  numl)er  of  pregnancies  or  miscarri- 
ages the  patients  had  had  before  being  opc^'ated  upon. 

In  five  other  cases  we  encountered  myomata  and  pregnancy  at  operation. 
In  Case  C.  H.  I.,  620,  the  woman  was  thirtv-hve  vears  old,  and  during  fifteen 


Fio.   382. — A   Larc:?;   Pkduncui ated   Subpkritonkat,   Myoma    Cumiiii  ahm;    ritKiiNANCY.     (J    iiat.   size.) 
Path.  No.  740.     (Specimen  sent  by  the  late  Dr.  Stansbury  Sutton,  of  PittsburR.)     The  uterus  measures  9.5 
X  11  X  12  cm.,  the  increase  in  size  being  due  to  the  pregnancy.     The  tubes  ami  ovaries  are  normal.     .Vttached 
to  the  posterior  surface  of  the  uterus  by  a  very  l)road  base  is  a  markedly   inMiular  in\ oiiiatous  mass,  which  meas- 
ures 9x11x12  cm.     For  the  interior  of  the  uterus  see  Fig.  383. 


years  of  married  life  had  iie\'ei-  been  j)regnant,  but  had  missed  her  last  two 
periods.  l''or  months  she  iiad  been  aware  of  a  nodular  gi'owth  in  the  lower 
abdomen.  When  the  abdomen  was  opened,  a  large  subpei-itoneal  nodule  was 
noted,  'i'he  uterus  was  slightly  enlarged  and  rather  .soft,  so  that  a  j)regnancy 
was  suspected.  As  the  cervix,  however,  was  very  hard,  and  as  the  patient 
had  remained  sterile  throughout   fifteen  years  of  her  married  life,  W(>  excluded 


644 


MYOMATA    OF    TUK    UTKRUS. 


a  pregnancy  and  performed  a  hysterectomy.  As  will  be  seen  from  the  accom- 
panying history,  the  uterus  contained  a  small  fetus. 

In  (  a.se  650S  the  pregnancy  was  recognized  clinically,  and  an  attem))t  was 
made  to  rcmox-c  the  large  myomata  witlio\it  distui-l»ing  gestation.  The  bleeding 
was  so  alarming,  however,  that  complete  removal  of  the  uterus  was  deemed 
necessary  in  order  to  save  the  patient's  life. 

In  Case  12902  a  widow,  forty-four  years  of  age,  gave  a  history  of  having  missed 
her  jx'riod  li\c  months  before  admission  and  of  some  distention  of  the  alxlomen. 
A  large  nuiltinodular  uterus  was  detected,  and  the  breasts  were  full  of  colostrum. 
After  carefully  weighing  the  contlition,  the  operator  decided  to  remove  the  uterus, 


Fig.  383. — A  Normal  PREOXANfv  Asso<iatkd  with  a  Largk  Sibi'kkiionkai.  .Myoma,     (i  nat    size.) 
Path.  No.  740.     (Specimen  sent   by  the  late  Dr.  R.  Stan^bury  Sutton,  i     The  picture  represents  the  uterus 
in  Fig.  382  after  being  oijcned.     The  uterine  walls  ajjpear  normal.     The  placental  attachment  presents  the  usu;  1 
appearance,  and  the  fetus,  which  measures  0..t  cm.  in  length  in  its  doubled-up  i)<;sition,  is  perfectly  normal. 

The  myoma  did  not  appear  in  any  way  to  he  impeding  the  growth  of  the  fetus.     The  only  suspicion  of  a  myoma 
s  furnished  by  a  small  subperitoneal  nodule  on  the  left 


feeling  that,  from  the  ])osition  of  the  tumors.  deli\cry  of  a  normal  child  would 
be  im])o.ssiblc. 

'i1ic  pathologic  rc])ort  shows  that  the  largest  myoma  was  12  cm.  in  diameter. 
and  that  there  were  also  several  .submucous  nodules. 

Fig.  38(5  shows  the  enlarged  uterus  in  Case  12r)S7.  Tlie  patient  had  mi.s.sed 
two  periods,  but  on  admission  the  breasts  contained  no  colostrum,  and  there  was 
a  brownish  vaginal  discharge.  The  cervix  was  larger  than  normal,  but  firm. 
Hy.sterectomy  was  performed,  but  when  the  uterus  was  oj)ene(l  a  small  fetus 
was  found.  In  this  case  a  continuation  of  the  j)regnancy  would  hai'dly  have  been 
possible. 


PREOXAXrY    AXI)    I    li:!;!  .\  K    MVdMATA. 


()4o 


In  Case  2434  the  patient  was  over  seven  months  j)retz;nant.  In  the  fun(his 
were  several  myomata,  and  l)h)okino;  the  pelvis  was  a  eei-A-ieal  myoiiia,  10  cm.  in 
diameter.  The  patient  eomijlained  of  constant  ])aiii  in  the  lower  alxloiiieii. 
Normal  lahoi'  was  out  of  the  ((uestion.  The  ])reii-nan('y  was  allowed  to  advance 
as  far  as  possible,  and  Cesarean  section,  followed  by  supi'avaginal  hysterecti^my. 


Fici.  384. — A   Prkgnant  Mui.tinoullak  .NUum  \  i  m  s   l-nurs.      (^  nat.  sizp.l 
Path.  No.  8325.      (Specimen  .sent   liy  Hr.  GeorKe  Ben  Johnstcn.  nf  Kicliiunn.l.  Vii.)     This  pear-shiiix'il  uteni.s 
measured   16x16x25  em.      Scattererl  over  its  entire  surface  are  larKe  ami   small   suhperiloneal   m.voniatu.      The 
api)en<lages  on  both  siile«  are  normal,  but   the  left  tube  i.s  inserteil    on   a   liidher   level    than   is   that   on  the  rijtht. 
For  the  ai)poarance  of  the  iiitericjr  of  tlu'  uterus  see  l"\ir,  ;\Sr>. 

was  ])ei"fornied.  'Hie  niolher  made  a  i^ood  recoxci'y.  but  the  child  ilieil  siiddeidy 
without  aj)pareiit  cause  twenty  hours  after  o])eralioii. 

The  specimen  shown  in  i'^igs.  3S2  and  '.\s:\  was  seiil  to  us  by  the  hite  Dr.  1\. 
Stansbury  Sutton,  of  Pit  Isbiirti,  I'a.;  and  ih.al  in  l'"i,iis.  .'>S  1  ami  .'IS,")  by  |)i-. 
(leoriic  Hen  Johnston,  of  llichnioiid,  \  a. 

Changes  in  the  Myomatous  Uterus  Due  to  Pregnancy.  —  ( 1  r  o  s  s  ('  h  a  ii  iz;  e  s  . 
— The  ceiA'ix  is  usualU'  nnich  softer,  but   in  some  of  our  cases  it   was  \-er\-  hard. 


646  .MYOMATA    OF   TH  K    ITERUS. 

On  opening  the  abduuicn  one  i>;  instantly  iiii|)ivss('d  by  the  niarkccl  increase 
in  vascularity,  as  noted  in  Case  6508,  in  which,  on  account  of  the  ahirming 
bleeding,  niyoniectoniy  had  to  l)e  abandoned  and  hysterectomy  ])erformed. 
The  tremendously  increased  blood-sui)|)ly  may  give  the  uterus  a  dark,  purplish- 
red  color,  as  was  seen  in  Case  125S7. 

Whether  the  jjrcgnancy  is  in  any  A\ay  mccliaiiically  interfered  with  will 
depend,  of  course,  on  the  position  of  the  tumors.  In  Fig.  3S2  we  see  an  enlarged 
pregnant  uterus,  with  a  l)road-based,  lobulated,  subperitoneal  myoma  attached 
to  its  posterior  surface  From  Fig.  383  we  see,  however,  that  the  tumor  in  no 
way  had  encroached  upon  the  uterine  cavity,  and  the  development  of  the  child 
was  ])roceeding  normally. 

Fig.  384  shows  a  uterus  fairly  riddled  with  myomata,  small  and  large  nodules 
projecting  forward  from  the  surface.  The  interior  of  this  uterus,  as  seen  in  Fig. 
385,  shows  that  there  were  also  interstitial  and  submucous  myomata,  and  that, 
where  the  myomata  were  subnuicous,  the  placenta  was  atrophic  or  missing. 
Nevertheless,  pregnancy  was  ])roceeding  in  an  orderly  fashion. 

I''ig.  ."JSO.  from  Case  12587,  shows  a  dense,  multinodular  uterus,  with  one  small 
submucous  myoma  and  an  early  pregnancy.  A  full-term  pregnancy  was  almost 
out  of  the  question  in  this  case,  and  the  premonitory  signs  of  miscarriage  were 
already  present.  If  the  child  had  become  viable,  the  cervical  myoma  (a)  would 
have  prevented  delivery  by  the  normal  channel. 

Nature  has,  however,  the  happy  faculty  of  sometimes  accomplishing  what 
seems  most  improbable.  Case  7549  affords  a  brilliant  example.  Seven  weeks 
after  a  normal  laboi-  a  large,  densely  adliei'ent  myomatous  uterus  was  removed. 
Pilling  U])  the  entire  uterine  cavity  was  a  .sloughing  submucous  myoma,  9  x  15  cm. 
This  case  is  illustrated  on  p.  65. 

Histologic  Changes  . — The  indi\idual  muscle-fibers  are  considerably 
swollen,  and  the  nuclei  are  usually  more  vesicular.  They  may,  however,  stain 
more  deeply  and  be  irregular  in  outline,  as  was  noted  in  Case  12587. 

In  addition  to  th(>  changes  in  the  muscle-fibers,  th(re  is  usually  swelling  of  the 
stroma  cells  between  the  muscle-l)undles. 

Hyaline  areas  in  the  myomata  seem  to  show  an  increased  tendency  to  melt 
away  when  associated  with  pregnancy.  This  is  strikingly  seen  in  Fig.  84  (p. 
106). 

Disappearance  of  Myomata  after  Pregnancy. — It  is  claimed  that  in  a  few 
instances  myomata  that  were  clearly  palj^able  before  and  during  pi'cgnancy  dis- 
ap])eared  shortly  after  labor.  We  have  never  .seen  any  evidence  su))porting  this 
view,  but  our  experience  with  pregnancy  associated  with  myomata  has  been 
too  limited  to  enable  us  to  speak  with  any  degre(>  of  certainty  on  this  point. 


Fig.  38.5. — Pregnancy  in  a  Multinoijui.ar  Myomatous  Uterus. 
Path.  No.  8325.     (Specimen  sent  by  Dr.  George  Ben  Johnston,  of  Richmond,  Va.)     For  the  appearance  of 
the  intact  uterus  see  Fig.  384.     Scattered  throughout  the  walls  are  interstitial  and  submucous  myomata.     The 
fetus  looks  normal,  and  from  the  head  to  the  buttocks  mea.sures  16  cm.  in  length.     Where  the  myomata  pro- 
ject into  the  uterine  cavity  the  phicenta  is  very  thin  or  entirely  wanting.      'I'his  is  i)artioularly  well  seen  at  a  anil  a\ 


PREGXAN'CY    AXD    UTElil.XE    .MYo.MATA. 


647 


Vu:.  :',s.-> 


048  myo.mata  uf  tiik  itkhus. 

Myomata  associated  with  Pregnancy. 

Gyn.  No.  6508. 

I'^  a  1- 1  y  P  ]■  ('  <2;  n  a  11  c  y  i  n  a  M  >'  o  111  a  t  o  ii  s  V  t  c  r  u  s  ;  M  y  o  m  e  c  - 
t  0  111  y  w  a  s  a  t  t  c  111  p  ted.  h  u  t  II  y  s  t  c  r  c  c  t  o  111  y  h  a  d  t  o  h  c  j)  e  r- 
foi'iiicd    oil    account     of    t  li  0    alarining    h  c  111  o  i' i- h  a  g  e  . 

A.  ("..  iiiari-i('(l,  aged  thiily-foiir,  while.  Admitted  November  14;  dis- 
charged Decemher  20,  1S*)S.  There  has  been  no  How  for  the  hist  six  weeks. 
The  entire  i-ighl  sith'  of  the  abdomen  is  on  a  higher  level  than  the  left. 

I'^xamination  under  Ether. — An  irregular  tumor,  apjiroximately  11  x  12  cm., 
is  felt  low  down  on  the  right  side  of  the  abdomen.  The  mass  is  veiy  hard, 
and  appears  to  be  made  up  of  a  number  of  superficial  l)osses  with  shallow  sulci 
between  them.  The  tumor  is  freely  movable,  and  can  easily  be  ])ushe(l  over 
to  the  left  side.  On  vaginal  examination  the  outlet  is  found  to  be  slightly 
relaxed.  The  cervix  is  well  back,  is  soft  and  flabby,  and  instantly  suggests 
pregnancy.  In  the  anterior  fornix  is  a  small,  liard  nodule.  The  uterus  itself 
aj)p;irently  contains  a  three  or  four  months'  ])regnancy.  ()))eration,  hystero- 
myomectomy. 

On  section  of  the  abdomen,  the  fundus  is  found  to  be  dark  purple  in  color, 
much  enlarged,  and  ti'av(>rsed  by  greatly  distended  vessels.  Springing  from  the 
uj)j)er  anterior  surface  of  the  fundus  is  a  pedunculated  myoma,  about  12  cm.  in 
diani(>ter.  Pi'oj(>cting  from  t  he  anterior  surface  of  the  uterus  is  a  smaller  myoma, 
about  S  cm.  in  diameter.  .Myomectomy  was  decided  upon,  and  the  small  myoma 
was  reiiKA'cd  through  a  circuhw  incision.  lvemo\al  was  instantly  followed  l)y  a 
profuse  hemorrhage,  which  was  at  once  controlled  l)y  gras])ing  the  incision  with 
the  fingers.  Attempts  wei'e  made  to  control  the  l)leeding  with  sutures;  but 
there  was  much  oozing  from  the  needle  j)unctures.  Bleeding  ])oints  were  grasped 
with  artery  forceps,  but  a  broad,  deep  sinus  was  opened,  and  a  teriific  hemorrhage 
foIIow(Ml.  The  uterine  muscle  tore  wherev(M"  th(>  force])s  were  applied.  It  was 
lound  that  the  only  hope  of  sa\'ing  the  patient  was  to  remove  the  uterus. 
.\n  assistant  grasped  the  cei'vix  tightly  with  his  hand,  and  thus  controlled  the 
bleeding.  The  uterus  was  remo\-e(l  in  the  usual  manner.  The  ))atient  made 
a  satisfactory  recovery. 

Gyn.  No.   12587.     Path.  No.  9348. 

II  y  s  t  e  r  o  m  y  o  m  e  c  t  o  111  y  .  T  h  e  V  t  e  r  us  ('  o  n  t  a  i  n  e  d  a  T  wo 
Months'  Fetus  (Fig.  ;-5S()).  Death  on  the  Fifth  Day, 
f  r  o  m     H  r  o  n  c  h  o  p  n  e  u  m  o  n  i  a  . 

S.  .).,  married,  aged  thiily-nine.  .\dmitt{Ml  December  oO,  H)0o;  died  Janu- 
ary 7,   1906. 

For  the  last  year  and  a  hall'  the  periods  ha\'e  been  increasing  in  length, 
sometimes  lasting  thirteen  days.  Seven  months  ago  a  tumor  was  noticed  in  the 
hnver  abdomen.     Her  last  period  was  two  months  before  admission,  but  two 


PRKGXAXrV    AXD    UTKRIXI-:    MYOMATA.  649 

weeks  ago  there  was  a  bloody  discharge  foi"  two  or  three  days.  For  the  hist  two 
weeks  she  has  been  losing  her  a])i)('tit(\  and  has  had  some  nausea  and  vomiting. 
She  has  been  forced  to  remain  in  bed  for  the  last  ten  days.  The  breasts  contain 
no  colostrum.  The  lower  |)art  of  the  abdomen,  as  fai'  as  the  umbilicus,  is  filled 
with  a  firm,  nodular  mass.  A  brownish,  mucous  discharge  escapes  from  the 
vagina.  The  cervix  is  larger  than  normal  and  is  firm.  The  history  is  suggestive 
of  pregnane}'  with  myoma,  but  the  examination  is  not  conclusive. 

Operation. — On  section  of  the  abdomen  a  dark,  purplish-red,  myomatous 
uterus  was  encountered.  The  uterus  was  boggy  and  suggested  pregnancy. 
The  vessels  of  the  ovarian  ligaments  were  greatly  distended. 

Hysterectomy  was  carried  out  in  the  usual  maimer,  the  uterus  being  am- 
putated through  the  cervix. 

The  operation  was  a  very  difficult  one.  The  j)atient  left  the  table  in  a  poor 
condition.  On  the  following  day  her  leukocytes  were  80,600;  the  temperature 
was  102.6°  F.     She  developed  a  pneumonia  and  died  on  the  fifth  day. 

The  autopsy  showed,  however,  that  a  general  peritonitis  was  the  immediate 
cause  of  death.  There  was  an  acute  fibrinous  pelvic  peritonitis ;  thrombosis  of  the 
uterine  and  vesical  veins,  thromV)oses  in  the  |)ulm()iiary  arteries,  jjulmonary 
abscesses,  bronchopnevmionia,  acute  bronchiectasis  and  bronchitis,  acute 
fibrinous  pleuritis,  acute  diphtheric  colitis,  cloudy  swelling  of  the  viscera. 

Path.  No.  934S.  The  uterus  (Fig.  386)  measures  16x13x14  cm.,  and  is 
markedly  nodular.  Covering  the  posterior  surface  are  many  adhesions,  and 
springing  from  the  fundus  is  a  sessile,  mulbeny-shaped  nodule,  4xo  cm. 
There  are  also  numerous  other  nodules  springing  from  the  anterior  and  jios- 
terior  walls.  Scattered  throughout  the  uterus  are  nodules  of  various  sizes.  The 
uterine  cavity  contains  a  small  fetus,  which  lies  just  beneath  the  small  sub- 
mucous myoma  (rl).     The  myoma  projects  a  short  distance  into  the  sac. 

Histologically,  the  uterine  mucosa  presents  the  tyjMcal  i)icture  of  pregnancy. 
Over  the  submucous  nodule,  which  ])i()jected  into  the  uterine  caN"ity,  there  is 
considerable  decidual  formation,  l)ut  no  glands.  It  is  interesting  to  see  tlu> 
swelling  of  the  nmscle-fil)ers  and  the  stroma  cells  between  the  nniscle-bundles. 

In  this  case  signs  of  mi.scarriage  had  ah'ead>'  appeai'ed,  and  had  the  chiM 
come  to  term,  the  myoma  (a),  as  seen  in  Fig.  386,  would  haxc  preveiiteil  deh\-ery 
through  the  natural  passages. 

Gyn.  No.   12902.     Path.  No.  9840. 

A  Multinodular  Myomatous  F  t  e  f  u  s  ('(tntaining  a 
V  Y  e  g  n  a  n  c  y      B  e  t  w  e  e  n     T  w  o     a  n  d     T  h  r  e  e     M  n  n  t  h  s  . 

F  L.  P.,  white,  widow,  aged  forty-four.  .\dniitti'd  May  o;  disehai'ged  May 
27,  1906. 

The  ])atient  has  had  no  menstrua!  distui'bance  imtil  a  few  months  ago,  wIkmi 
the  flow  began  to  increase.  I*'oui'  months  ago  the  peiiods  ceased,  and  it  was 
thought  the  men 01  la use  was  fomimi:  on.      I  )uiini:;  the  lasi  h\-e  nidiit lis  the  abdomen 


650  MYO.MATA    OF    THE    UTERUS. 

has  rapidly  increased  in  size.  She  experienced  no  pain  until  a  month  ago,  when 
she  was  confined  to  bed  for  ten  days.  The  pain  was  ''jumping  and  gnawing" 
ill  character.  The  breasts  were  large  and  full  of  colostrum.  On  examination 
under  ether  the  tumor  is  found  to  extend  two  inches  above  the  umbilicus,  and  on 
the  left  side  reaches  the  umbilicus.  There  is  some  blueness  of  the  mucosa.  The 
cervix  is  firm,  the  os  slightly  ])atulous.  The  fundus  cannot  be  made  out  dis- 
tinctly, but  it  appears  to  be  continuous  with  the  abdominal  mass. 

The  history  and  the  examination  pointed  to  pregnancy  at  about  the  fourth 
month,  but  on  account  of  the  markedly  myomatous  condition  of  the  uterus, 
it  was  thought  that  the  patient  would  not  be  al)le  to  go  to  term. 

Operation.  On  section  of  the  abdomen  the  irregular  and  myomatous  uterus 
showed  at  least  fifteen  myomata  scattered  over  its  surface.  .-Vll  the  uterine 
vessels  seemed  dilated,  and  the  body  of  the  uterus  was  rather  l^oggy.  All  the 
tissue  was  so  vascular  that  even  the  smallest  bleeding  point  had  to  be  tied. 
The  patient  stood  the  operation  well  and  made  a  good  recovery. 

Path.  No.  9840.  The  uterus  has  been  amputated  through  the  cervix.  It 
measures  api)i-()ximately  10  cm.  in  breadth,  24  cm.  in  length,  and  13  cm.  in  its 
anteroj)osterior  diameter.  The  great  increase  in  size  is  due  to  the  presence  of 
many  myomatous  nodules,  the  largest  of  which  is  approximately  12  cm.  in  di- 
ameter and  subperitoneal.  There  are  also  numerous  small  ones,  some  of  which 
are  subnmcous.  The  uterus  contains  a  fetus  which  is  between  three  and  four 
months  old. 

Sections  from  the  endometrium  show  typical  decidua,  and  we  have  here 
and  there  in  it  areas  of  coagulation  necrosis  and  infiltration  with  small  round 
cells — an  indication  that  a  miscarriage  would  s(xjn  have  occurred.  The  muscle- 
fibers  in  the  myoma  show  a  slight  increase  in  size. 

C.  H.  I.  620.     Path.  No.  8827. 

A  n  K  a  r  1  y  P  r  e  g  11  a  11  c  y  D  i  s  c  o  v  e  r  e  d  a  f  t  e  r  Re  m  oval  of 
t  h  e     I'  t  e  r  u  s  . 

E.  S.,  married,  aged  thirty-five,  white.  Admitted  May  29:  discharged 
June  24,  1905. 

The  patient  had  been  married  for  fifteen  years.  Init  had  nc\Tr  been  thought 
to  be  j)regnant.  She  had  missed  two  periods,  however,  just  before  admi.ssion. 
Upon  pelvic  examination  a  myomatous  uterus  was  diagnosed  and  an  operation 
advised,  as  there  had  been  a  great  deal  of  abdominal  pain.  On  ojiening  the 
abdomen  we  found  what  appeared  to  be  a  large  myomatous  nodule.  The  uterus 
was  slightly  enlarged  and  rather  soft.     We  considered  the  po.s.sibility  of  preg- 


FiG.  386. — An  Early  Pregnancy  in  a  Myomatous  Uterus.     («  nat.  size.) 
Gyn.  No.   12587.     Path.  No.  9348.     The  entire  specimen  measured   13x14x16  cm.     There  are  numerous 
subperitoneal  and  interstitial  myomata.     The  specimen  has  been  opened  from  the  front,     a  is  a  cervical  myoma 
that  would  have  certainly  prevented  a  normal  labor;    b  is  a  shaggy  placental  covering  of  the  fetal  sac;  c,  a  blood- 
clot;   d  is  a  -small  submucous  m.voma  that  encroaches  on  the  embryonic  sac;    e  is  the  thickened  uterine  mucosa. 
In  the  right  lower  corner  is  a  sketch  shf)\vinK  the  relation  of  the  submucous  myoma  to  the  amniotic  sac. 


Fic.  :«r). 


651 


652  MYOMATA    OF   THE    UTERUS. 

nancy,  hut  the  cervix  was  very  hard.  The  uterus  was  removed,  and  the  patient 
speedily   recovered. 

Path.  Xo.  8827.  The  specimen  consists  of  a  myomatous  uterus,  amputated 
through  the  cervix.  The  uterus  contains  a  small  fetus,  1.5  cm.  in  length.  The 
uterus  itself  is  nodulai',  and  is  16.5  cm.  broad,  8  cm.  in  length,  and  8.5  cm.  in 
its  anterojjosterior  diameter.  The  largest  myoma  is  approximately  11  cm. 
in  diameter,  and  there  is  a  diffu.se  myomatous  thickening  in  the  other  ]K)rtions  of 
the  wall. 

Sections  from  the  endometrium  show  the  typical  ])icture  of  pregnancy.  The 
muscle-fibers,  ])articularly  beneath  the  mucosa,  show  some  thickening. 

S(>ctions  from  the  myoma  show  typical  and  wide-spread  hyaline  degenera- 
tion, only  a  few  fibers  remaining  here  and  there.  The  interspaces  are  divided 
by  ;i  substance  that  is  granular  (Fig.  84,  p.  106).  In  ])laces  it  stains  slightly, 
at  other  points,  deeply,  the  intensity  of  the  stain  indicating  the  density  of  the 
fluid  filling  the  spaces. 

Diagnosis:  interstitial  uterine  myomata,  complicated  by  a  pregnancy  of 
Ix'tween  two  and  three  months. 

Gyn.  No.  2434.     Path.  No.   186. 

Pre  g  n  a  n  c  y  i  n  a  M  y  o  m  a  t  o  u  s  Uterus.  Cesarean  Sec- 
tion     followed      by    S  u  ])  r  a  v  a  g  i  n  a  1     H  y  s  t  e  r  e  c  t  o  m  y. 

Mrs.  1).  S.,  aged  thirty-six,  white,  admitted  November  28,  1893;  discharged 
April  2,  1894.  The  jxdient  had  had  one  child  and  one  miscarriage.  Fetal 
movemeiUs  were  first  noticed  on  October  16th.  The  patient  was  not  positive 
when  the  menses  had  cea.sed.  She  complained  of  constant  pain  in  the  lower 
abdomen.  After  waiting  nearly  two  months.  Cesarean  section  was  performed, 
as  a  large  cervical  myoma,  10x8x8  cm.,  choked  the  pelvis.  After  delivery 
of  the  child  the  uterus  was  amputated  at  the  cervix.  The  patient  made  an 
uninterrupted  convalescence.  The  child  died  twenty-four  hours  after  operation, 
without  any  apparent  cause. 

Path.  Xo.  186.  The  contracted  uterus  is  16x16x18  cm.  In  addition  to 
the  large  cervical  myoma  there  are  several  others  scattered  throughout  the  uterine 
walls.  The  largest  of  these  is  5  cm.  in  diameter.  A])art  from  the  numerous 
myomata  the  uterus  presented  the  usual  appearance. 

After  studying  the  histories  the  reader  may  feel  that  j)oor  surgical  jutlgment 
was  shown  in  some  of  the  cases.  In  one  case  the  myomatous  uterus  reached 
large  ))roporlions,  and  in  the  cervix  was  a  myoma  that  would  have  effectually 
blocked  normal  delivery.  In  other  cases  there  were  already  premonitory  signs 
of  miscarriage.  It  is  easy  to  look  l)ack  and  see  where  im])rovements  might  have 
been  made.  In  some  instances  it  is  difficult  accurately  to  determine  the  con- 
dition until  the  abdomen  is  opened.  With  the  exact  condition  before  him  the 
operator,  on  the  one  hand,  wishes  to  l)e  c(jnservative  and  not  interfere  with 


PREGXAXCY    AXD    UTKRIXH    MYOMATA.  653 

gestation,  Init,  on  tlic  other  liand,  he  rcalizos  that  there  is  a  ju'cuhar  proneness 
for  these  patients  to  niiseaiTV.  and  lie  also  knows  tliat  if  snhmueous  myoniata 
exist,  they  are  liai)le  to  become  infected.  Furthermore,  he  cannot  lose  sight  of 
the  fact  that,  if  radical  ])rocediires  are  deferred,  in  the  near  future  it  will  become 
necessary  to  again  subject  the  ])atient  to  an  abdominal  operation.  In  one 
or  two  of  our  cases  it  would  have  been  wiser  hail  we  watched  thej)atient,  for 
a  few  months  at  least. 

The  aim  in  each  case  should  be  to  effect  a  normal  delivery  at  term,  if  that  be 
possible,  after  which,  if  it  be  deemed  necessary,  the  myomata  or  the  utei-us 
can  be  removed. 

Recenth'  Bland-Sutton  has  drawn  attention  to  what  he  terms  red  degenera- 
tion of  myomata  occurring  during  pregnancy.  Our  exj)erience  with  myomata 
in  pregnancy  has  been  so  limited  that  we  have  had  little  opixirtunity  of  study- 
ing this  form  of  degeneration. 


CIIAPTEl^  XXXI\\ 
COMPLICATIONS  FOLLOWING  ABDOMINAL  HYSTEROMYOMECTOMY. 

Hemorrhage. — Scooiularv  hcinorrha^r  after  alxloniinal  hystorcctomy  has, 
fortunately,  l)eeii  coiiij)aratively  rare  in  our  series.  In  recent  years  we  have 
made  it  a  rule  to  tie  all  the  cardinal  vessels  twice,  so  that  if,  by  any  chance, 
one  ligature  is  not  tight  enough,  the  second  will  effectually  prevent  bleeding. 

In  Case  3997  a  densely  adherent  myomatous  uterus,  18  x8  x  10  cm.,  was  re- 
moved through  the  abdomen.  After  operation  the  pulse  become  very  weak 
and  rapid.  Hemorrhage  was  suspected,  although  no  other  signs  of  bleeding 
were  noted.  The  abdomen  was  reopened  twenty-four  hours  after  the  o])eration, 
and  a  large  quantity  of  free  and  clotted  blood  was  found.  The  bleeding  was  from 
the  left  ovarian  artery.  This  was  reticd  securely.  At  the  end  of  the  operation 
the  j)ulse  was  160.  A  liter  of  saline  solution  was  introduced  under  the  breast. 
The  patient  was  discharged  well. 

In  Case  7330  the  multinodular  uterus  extended  half-way  to  the  umbilicus. 
One  of  the  nodules  had  encroached  markedly  on  the  anterior  vaginal  wall.  On 
the  tenth  day  a  hematoma  was  detected,  which  lay  in  front  of  the  cervix  and 
filled  both  broad  ligaments  as  far  as  the  ])elvic  brim.  Through  a  vaginal  o])ening 
the  clot  was  removed  and  the  cavity  lightly  packed.  The  patient  was  discharged 
well  on  the  twenty-seventh  day.  In  this  case  the  bleeding  was  in  all  probability 
due  to  a  continuous  ooze  from  small  vess(^ls,  and  did  not  come  from  an  artery 
or  vein  of  any  appreciable  size. 

In  Case  9736  a  boggy,  adherent,  myomatous  uterus  was  removed,  together 
with  the  adherent  a])pcndages.  The  abdominal  wound  bi'oke  down.  In  the 
pelvis  was  an  accumulation  of  lilood,  and  in  both  broad  ligaments,  clots. 
The  thickening  was  more  marked  on  the  right  side.  V'aginal  section  was  done, 
the  pelvis  drained,  and  the  clots  were  removed.  Rapid  recovery  followed.  In 
this  case  also  the  bleeding  was  a])])arently  due  to  oozing  rather  than  to  any  free 
hemorrhage. 

In  Case  3977  the  catgut  ligature  controlling  the  left  uterine^  artery  absorbed 
too  ra])idly,  and  the  ])atient  died  fi-oiii  hemorrhage  on  the  eighth  day.  This  case 
is  described  in  detail  on  p.  681. 

S  y  m  p  t  o  m  s  Suggesting  11  e  m  o  r  r  h  a  g  e  . —  In  Case  3492  hystero- 
myomectomy  was  done  and  the  patient  had  a  sudden  fainting  spell  on  the 
nineteenth  day;  the  pulse  rose  to  130,  the  res{)irations  became  rapid,  the  hands 
were  clanmiy,  and  she  presented  th(>  ])icture  of  hemorrhage.  The  abdomen 
was  opened  with  negative  results.  The  case  was  later  su{)posed  to  be  one  of 
pulmonary  embolism.     It  is  rej)()rted  in  detail  on  p.  ()()9. 

(554 


COMPLICATIONS    FOLLOWING    ABDOMINAL    HYSTEHOMYOMECTOMY.  655 

In  such  cases  as  this  it  is  usually  much  hcttcr  to  explore  the  abdomen  at  once. 
Naturally,  the  already  existing  depression  is  intensified  to  some  extent  ijy  the 
anesthetic  and  the  exploration,  but  through  a  very  small  opening  one  can  at  once 
determine  whether  the  abdomen  contains  free  blood  or  not.  If  there  is  hemor- 
rhage and  prompt  action  is  deferred,  the  patient  may  be  too  weak  to  stand 
any  operation  when  the  diagnosis  becomes  certain.  Where  there  are  definite 
signs  of  hemorrhage,  the  abdomen  should  be  opened  at  once. 

Elevation  of  Temperature. — In  reading  the  postoperative  histories  of  patients 
from  whom  a  myomatous  uterus  had  been  removed  through  the  abdomen,  we 
have  often  been  surprised  to  see  it  stated  that  the  patient  had  absolutely  no 
elevation  of  temperature.  This  has  not  been  our  experience.  From  the  ac- 
companying tabulation  of  100  uncomplicated  abdominal  hysteromyomectomies, 
taken  in  their  regular  sequence,  it  will  be  seen  that  in  only  15  per  cent,  did  the 
temperature  remain  below  100°  F.  In  over  half  of  the  cases  it  at  one  time 
reached  some  point  between  100.2°  and  101°  F.,  and  in  five  cases  it  was  over 
102°  F. 

From  the  statistics,  as  frecjuently  published,  the  operator  would  be  alarmed 
if  the  temperature  reached  101°  F.,  but,  as  seen  from  the  table,  it  is  of  common 
occurrence,  and  in  the  absence  of  complications  should  occasion  little  uneasiness. 

TABLE  SHOWING  MAXIMUM  TEMPERATURE  IN  100  CASES  AFTER  AN  UNCOMPLI- 
CATED HYSTEROMYOMECTOMY. 
99       to  100       in    15  per  cent,  of  the  cases 
100.2    to  101       in    61  per  cent.     "     " 
101.2    to  102       in     19  per  cent.     "     "       " 
102.2    to  103.8    in      5  per  cent.     "     "       " 

100  per  cent.     "     "       " 

The  maximum  temperature  usually  occui's  within  four  da^^s  after  operation. 
It  was  present  on  the  second  day  in  52  per  cent,  of  the  cases,  as  seen  from  the 
second  table. 


DAY  OF  MAXIMUM 

POSTOPE 

HATIVE  TE.MPERATUHE 

First 

day 

after 

operation  in     1,")  jx-r  cciif. 

of  tlie 

cases. 

Second 

" 

.')2  per  cent. 

" 

Third 

" 

1.)  per  cent. 

" 

Fourth 

"          " 

4  per  cent. 

" 

Fiftli 

"          " 

6  per  cent. 

" 

Sixth 

''          " 

3  per  cent. 

Seventh 

"          " 

2  per  cent. 

Eighth 

2  per  cent. 

Ninth 

1  per  cent. 

Total  l(»()  per  cent. 


Hot  W  e  a  t  h  e  r  a  s  a  Can  s  e  o  f  P  o  <  i  o  p  c  r  ;i  live  K  1  <•  v  a  t  ion 
of  Temperature.  We  have  occasionally  noted  an  uiuisual  postoperative 
rise  of  temperature  in  patients  operated  upon   in  excessively  warm  weather. 


656  MYOMATA    OF    THK    UTRRrS. 

Whether  this  rise  is  depemlcnt  111)011  the  atmospheric  condition  or  not  it  is  impos- 
sible to  say.  but  the  re])eated  coexistence  of  these  two  phenomena  strongly  sug- 
gests that  hot  weather  predisposes  to  a  postoperative  elevation  of  temperature. 

Pulse. — With  the  elevation  of  temperatui'e  that  u.sually  follows  an  abdominal 
hysteromyomectomy,  thei'e  is  naturally  an  acceleration  in  the  pulse-rate. 

KAXC.E  OF  THK  MAXIMIM  P()S'1(  )1'KHATI\  K  PILSK-HATE  IN  100  SIMPLE  AxND  SUC- 

CESSFl'L  AHI)( )MIXAL  HVSTEROMYOMECTOMIES. 

•10  to  100    in  32  per  cent,  of  tlie  cases 

lU'i  "    1-U    "    55  per  cent.   "     "       " 

122  "   130    "      7  per  cent.   "     " 

132  •'   140    "      6  per  cent.   "     "       " 

Total 100  per  cent.   "     " 

Tn  nearly  6S  per  cent,  the  pulse  reached  102  or  over  .shortly  after  operation. 
Tlif  tai)le  giving  the  day  of  most  rapid  |)ul.'^e-rate  shows  that  it  occurred  most 
fre(|uently  on  the  second  and  third  days  after  operation. 

DAY  OF  .MAXLMI'M  POSTOPERATIVE  PULSE-RATE. 
First  (lay  after  operation  in     13  per  cent,  of  the  cases. 

Second         "         "  "  "    41  per  cent.   "     "       " 

Third  "         "  "  "    2(1  per  cent.   "     "       " 

Fourth         "         "  "  "11  per  cent.   "     " 

Fifth  "         "  "  "      5  per  cent.   "     "       " 

Sixth  "         "  "  "      1  per  cent.   "     "       " 

Seventh       "         "  "  "      1  per  cent.   ■'     "       " 

Eisihth  "  "  "  "       1  per  cent.    "     "       " 

Eleventh     "         "  "  "      1  per  cent.   "     "       " 

Total 100  per  cent.    "     " 


A  Ik  a  pi  d  Pu  1  se. — When  the  myoma  has  been  complicated  l)y  i)Us-tubes 
or  a  pelx'ic  abscess,  it  is  perfectly  natural  tliat  tlie  pulse-rate  should  be  rai)id  not 
only  during,  but  also  after,  operation.  A  (|uickened  pulse  is  likewise  usually 
noted  when  jjeritonitis  is  de\'elo])ing. 

In  Case  <S495  the  ])atient  had  pal])itation  of  the  heart  and  shortness  of  breath, 
a.'^sociated  with,  and  ])i-obably  dependent  on,  an  eiilai'ged  tliyroid.  Spinal 
cocain  anesthesia  was  employed,  and  the  abdomen  oi)ened.  The  i)ain  was  so 
.•severe  that  ether  had  to  be  substituted.  Ilvsterectoiny  was  then  iierformed.  On 
leax'ing  the  table  the  patient  had  a  very  rapid  pulse  and  rapitl  and  sh;dlow  re.s- 
])irations.  The  jnilse  \-ai'ie(l  from  ISO  to  200  for  the  Hi'st  tweiUy-four  hours, 
and  then  gi'adually  became  slower. 

It  is  difhcult  to  determine  whether  the  sjjinal  anesthesia,  the  goiter,  or  l)oth 
wei'e  in  any  way  responsible  for  the  rapid  pulse. 

These  figures  will  naturally  vary  somewhat  in  diffei'ent  clinics,  but  it  is 
readily  seen  that,  e\-eii  in  the  sim|)le  uncom])licated  abdominal  hysteromyo- 
mectomies,  there  is  usually  a  definite  rise  of  temperatiu'c  and  pulse  at  some  jx'riod 
during  the  convalescence. 


COMPLICATIONS    FOLLOWING    ABDOMIXAL    HVSTEHO.M VOMECTOMY.  657 

Postoperative  Retention. — Pvctcntion  of  lu-inc  folluwino;  the  avemge  hystero- 
inyoniectomy  has  not  been  very  conmion  in  our  cxporiencc.  Where  the  bladder 
has  been  drawn  high  up  on  the  surface  of  the  tumor,  it  may  l)c  several  days  be- 
fore it  regains  its  normal  power  of  contractility,  and  temporary  retention  may 
occur.  When  the  bladder-walls  are  greatly  hypertrophied,  retention  may  occur, 
as  was  noted  in  Case  3445. 

As  a  result  of  the  removal  of  the  uterus,  the  position  of  the  bladder  is  naturally 
altered,  and  this  tends  to  produce  retention  for  a  short  period.  Supravaginal 
hysterectomy  causes  much  less  alteration  in  the  location  of  the  bladder  than  does 
a  panhysterectomy,  and  hence  the  tardy  vesical  evacuation  is  less  frequent  after 
the  supravaginal  operation. 

When  the  patient  finds  it  very  difficult  to  void,  a  hot-water  l)ag  may  be 
applied  over  the  bladder,  and  hot  douches  given.  Contractions  of  the  bladder 
may  also  be  favored  by  making  the  patient  sit  up,  if  it  is  deemed  .safe.  Catheteri- 
zation should  Ije  avoided  whenever  possible. 

Partial  Suppression  of  Urine. — In  Case  7240  a  large  myomatous  uterus  was 
removed  from  a  white  woman  aged  thirty-eight.  Prior  to  operation  she  had  had 
frequent  and  profuse  uterine  hemorrhages.  She  had  a  mitral  stenosis,  with  an 
accompanying  hypertrophy.  Her  hemoglobin  was  60  per  cent.  She  did  well 
until  the  tenth  day,  when  slight  dyspnea  was  noted.  There  was  some  edema 
of  the  face  and  legs,  and  a  rapid  pulse.  During  th(^  twenty-four  hours  she  voided 
only  300  c.c.  The  cardiac  dulness  had  increased,  and  the  heart's  action  resembled 
the  fetal  type.  Digitalis  and  Epsom  salts  were  administered,  and  the  patient 
drank  freely  of  cream  of  tartar  water.  She  was  discharg(Hl  on  the  twenty-fifth 
day  in  excellent  condition. 

The  partial  suppression  was  imdoubtedly  secondary  to  the  cardiac  lesion. 

Cystitis. — Inflammation  of  the  bladdc^r  very  frequently  follows  abtloniinal 
hysterectomy  for  carcinoma  of  the  cervix.  This  is  primarily  due  to  the  fact  that 
it  is  impossible  to  perfectly  sterilize  the  carcinomatous  growth,  and,  secondly, 
because  the  extensive  dissection  not  only  necessitates  free  handling  of  l  he  bladder, 
but  often  also  the  cutting  off  of  a  ])ortion  of  the  vesical  blood-supj)ly. 

Where  the  myomatous  uterus  is  removed  sui)ravaginall\'.  the  bladder  is 
usually  little  disturbed,  and  ])rovided  there  has  been  no  previous  abnormality 
in  this  viscus,  no  trouble  follows.  \\v  ha\'e  had  i-elati\'ely  few  cases  of  cystitis 
after  hysteromyomectomy. 

Nephritis. — We  shall  consider  here  only  those  cases  in  which  i-eco\'ery  took 
place.  Definite  signs  of  renal  insufficiency  were  noted  in  sevei-al  of  the  i)aliciUs 
who  (lied  of  general  peritonitis.     These  cases  are  discussed  a!   length  on  |>.  (173. 

In  Case  4S()<),  after  removal  of  a  lai'ge  myomatous  uterus,  a  I  I'ace  of  albumin 
and  some  hyaline  casts  were  noted.  The  convalescence,  howexci-.  was  not  in  any 
way  disturbed. 

In  Case  10101  the  urine  was  normal  befoi'e  o))eration.  .\fter  reinowil  of  a 
nmltinodular  uterus,  which  i-eached  the  umbilicus,  the  urine  contained  a  trace 
42 


658  MYOMATA    OF   THE    UTERUS. 

of  allKiniin,  and  some  hyaline  and  granular  casts.  The  temperature  reached 
102.5°  F.  twenty-four  hours  after  operation,  and  on  th(>  eleventh  day  reached 
103°  F.     The  patient  was  discharged  in  good  condition. 

Case  77()o,  in  which  a  severe  postoperative  nei)hi-itis  was  associated  with  a 
large  Ix'd-sore  and  acute  mania,  is  rejxjrted  in  detail  on  p.  (Hil. 

Edema  of  the  Legs. — Tn  Case  7240  hysterectomy  was  {x-rformed  for  a  very 
large  cervical  niyotna,  Ki  x  17  x  IS  cm.  The  i)atient  was  anemic,  and  the  cardiac 
dulness  was  increased.  The  heart -sounds  also  suggested  dilatation.  The  patient 
did  well  until  the  tenth  day,  when  the  pulse  became  weak,  intermittent,  and  rapid. 
There  was  slight  dys))nea,  and  some  edema  of  the  face  and  legs. 

Tinctui'e  of  digitalis  and  Fpsom  salts  were  adniinistei'ed,  and  cream  of  tartar 
water  was  given  lihei'ally.  The  patient  im))i-oved  ra{)idly  and  left  the  hos])ital 
twenty-five  days  after  ojH'ration.  The  edema  in  this  case  was  evidently  due 
to  the  cardiac   insulliciency. 

Nausea  and  Vomiting,  -Formerly  nausea  and  \'omiting  were  l(j(jke(l  for  after 
nearly  all  serious  abdominal  operations,  but  since  the  introduction  of  the  drop 
method  of  administering  ether,  the  giving  of  large  quantities  of  water  to  the 
patient  as  soon  as  siie  desires  it  after  operation,  and  the  raising  of  the  patient's 
head  on  pillows,  thereby  tending  to  carry  the  gastric  contents  downward  in- 
stead of  U]nvard.  our  experience  with  nausea  and  vomiting  has  been  remarkably 
diminished. 

Some  patients,  ho\ve\-ei',  show  a  peculiar  tendency  toward  nausea  and  vom- 
iting. In  Case  2()*)i),  in  which  the  operation  was  sim})le,  the  patient  had  almost 
constant  nausea  for  forty-eight  hours.  In  Case  2129  there  was  nausea  for  ten 
days,  but  only  slight  vomiting.  Tn  Case  2919  there  were  obstinate  nausea  and 
vomiting  for  the  first  six  days. 

S  t  e  r  c  o  r  a  c  e  o  u  s  \'  o  m  i  t  i  n  g  . — Fecal  vomiting  is  relatively  connnon 
in  cases  of  intestinal  obstruction  and  in  peritonitis,  l)ut  not  very  often  met  with 
in  patients  that  i'eco\-er. 

In  Case  9971  the  patient  had  carcinoma  of  the  cervix  and  adenomyoma  of 
the  body  of  the  uterus.  For  several  days  after  the  necessarily  extensive  hyster- 
ectomy she  had  excessive  naus(>a,  vomiting,  and  diai'i-hea,  and  also  fecal  vomiting. 
For  the  first  ten  days  after  operation  her  life  hung  in  the  balance,  l)ut  after  that 
the  convalescence  was  raj)id. 

Stercoraceous  material  was  washed  from  the  stomach  in  Case  2598,  several 
days  after  an  ai)doniinal  myoinectomy.     This  case  is  reported  in  detail  on  p.  548. 

D  a  r  k  -  b  r  o  w  n  \'  o  in  i  t  u  s  . — In  very  ill  ])atients  small  or  large  quanti- 
ties of  a  dark-brown  material  are  frequently  ejected  from  the  stomach.  This 
fluid  resembles  coffee-grounds  to  a  certain  extent.  The  coloring  is  in  part  due 
to  partly  digested  blood.  \Mienever  such  vomit  us  is  noted,  a  grave  prognosis 
should  be  given,  as  neai'ly  all  these  patients  die. 

Case  7560,  in  which  an  aljdominal  niyoniectoniy,  and  Case  5858,  in  which 


COMPLICATIONS    FOLLOWING    ABDOMINAL    HYSTKHOMYOMECTOMY.  Go9 

an    al)doniinal    hystcroctoniy,  had    been    performed    afford    typieal    examples; 
both  patients  died. 

Intestinal  Worms. — In  two  of  our  cases  lumbrieoid  worms  were  detected  after 
operation.  In  Case  7460  the  myomatous  uterus  nearly  filled  the  abdomen. 
Hysteromyomectomy  was  performed,  and  the  patient  made  an  uneventful  re- 
covery. On  the  eleventh  day  she  passed  a  lumbrieoid  worm,'  35  cm.  long. 
Ten  da3^s  later  santonin  was  administered,  with  the  result  that  a  large  number 
of  round  wonns  and  many  eggs  came  away. 

The  convalescence  in  Case  2706  was  not  quite  so  smooth.  After  a  hystero 
myomectomy  the  patient  had  persistent  nausea  and  vomiting  until  the  fourth 
day,  when,  after  an  ascaris  lumbricoides,  14  cm.  long,  had  been  vomited,  the 
nausea  and  vomiting  ceased. 

In  1894  Stavely  *  gave  an  interesting  account  of  the  symptoms  produced  by 
lumbrieoid  worms  after  abdominal  operations.  He  found  that  the  most  con- 
stant and  alarming  feature  in  such  cases  was  a  peculiarly  persistent  nausea  and 
severe  vomiting,  accompanied  by  colicky  pains,  disturbed  breathing,  an  anxious 
expression,  palpitation  of  the  heart,  and  a  general  feeling  of  malaise — a  complex 
of  S3aiiptoms  quite  different  from  the  simple  persistent  nausea  and  discomfort 
frequently  ol^served  after  anesthesia. 

Occasionally,  in  our  abdominal  work,  when  we  have  detected  worms  at 
operation,  they  were  squeezed  between  the  fingers,  later  a  cathartic  was  given, 
and  the  parasites  usually  came  away  dead  and  somewhat  macerated. 

Obstipation. — With  the  patient  in  the  recumbent  position  it  is  often  diflicult 
to  secure  a  proper  evacuation.  We  usually  rely  on  enemata  for  the  first  few 
days,  followed  later  by  some  mild  laxative.  The  tendency  to  obstinate  con- 
stipation is  especially  noticeable  in  very  stout  individuals. 

In  some  cases  the  tardy  bowel  evacuation  amounts  almost  to  intestinal 
obstruction.  This  was  especially  noticeable  in  Case  4172.  If  there  are  signs 
of  obstruction,  cathartics  are  contraindicated  absolutely.  A  harmless  but  efii- 
cient  laxative  is  castor  oil.     The  safest  plan  is  to  rely  entirely  on  enemata. 

Rectal  Tenesmus. — In  Case  3320  the  multinodular  myomatous  uterus  extended 
above  the  uml)ilicus.  For  the  first  thirty-six  hours  after  operation  there  were 
pronounced  sym{)toms  of  shock,  and  the  patient  had  marked  nrtal  tenesmus. 

Intestinal  Obstruction. — For  the  fatal  cases  of  obsti-uction  following  hystero- 
myomectomy see  p.  ()77. 

In  Case  109()9  the  patient  had  noticed  a  small  abdoiiiinal  tumor  for  o\-er 
thirty  years  before  admission.  At  the  time  of  operation  tlie  utei'us  icaehed  to 
the  umbilicus.  On  the  sixth  day  after  operation  a  loop  of  siunll  i)owel  was 
brought  out  and  oix'iied  on  account  of  intestinal  obst  iiiclion.  An  unsuccessful 
attempt  was  mack;  to  close  this  opening  foui' days  lalei-.      I'inall\,   however,  it 

*  Altjert  L.  Stascly.  liilcsliiiMl  Wdrriis  :is  ;i  Cornplic:!!  iini  in  .Muloiniiial  Surg(>ry,  .lolins 
H()})kins  IIosp.  I^cpDrts.  IS'.H.  \iil.  iii,  ]>,  :?71. 


660  MVOMATA    OF    THE    UTKUrS. 

was  cloi^ied  two  nionths  after  operation,  and  the  patient  dischai'ged  ])erfectly 
well. 

In  Case  12439  the  hirac  multinoduhir  uterus  was  adiierent  to  the  bowel  in 
Douglas'  cul-de-sac.  Durinji' liberation  of  adhesions  })urulent  accunnilations  in 
the  appendaii'es  on  both  sides  were  opened  up.  The  surrounding  structures 
were  walled  off  as  carefully  as  possil)le,  to  minimize  the  danger  of  infection.  Dur- 
ing the  operation  just  prior  to  closure  of  the  abdomen  the  pelvis  was  drained 
through  the  vagina. 

On  the  third  day  tlie  ])atient  vomited  and  hiccoughed  a  good  deal.  Her 
general  condition  was  worse,  and  she  had  a  spot  of  marked  tenderness  near  the 
umbilicus.  In  the  abdominal  incision  was  a  small  amount  of  slightly  blood- 
tinged  turbid  fluid.  The  intestines  were  moderately  distended,  and  had  lost 
their  glistening  appearance.  A  loop  of  distended  small  bowel  was  brought  out, 
suturcnl  to  the  abdominal  wall,  and  opened  S(>veral  hours  later.  The  fecal 
fistula  jM'i'sisted  for  over  two  months.  Finally  the  patient  was  discharged  in 
good  condition. 

Both  of  these  patii'uts  would  in  all  ])robability  have  died  had  not  the  enter- 
ostomy been  done.  In  all  cases  in  which  there  are  definite  signs  of  obstruction 
the  safer  ])rocedure  is  to  at  once  ex])lore  the  abdomen  and.  if  necessary,  do  an 
enterostomy. 

Fistula  in  Ano. — In  Case  7859,  the  patient,  aged  fifty-two,  white,  as  a  result 
of  the  excessive  menstrual  How,  had  become  \-erv  weak.  Her  hemoglobin  was 
30  ])er  cent,  and  a  soft  systolic  tmirmur  was  audi!)le  over  the  entire  precordial 
region.  A  huge  nmltinodular  and  adherent  myomatous  uterus  was  removed. 
At  the  time  of  her  discharge  from  the  hospital  her  hemoglobin  had  risen  to 
59  per  cent.  One  inch  to  the  right  of  the  anus  was  a  small  fistulous  opening 
from  which  a  dark  gra>ish  material  was  discharging.  The  surrounding  tissues 
wei"e  indurated. 

Cardiac  Complications. — We  shall  include  here  only  those  cases  in  which  re- 
covery took  place.  As  noted  on  ]).  453,  many  of  our  patients  have  had  a  very 
low  hemoglol)in,  and  it  is  remarka!)le  that  so  few  manifested  abnormal  cardiac 
symptoms  following  ojx'ration. 

In  Case  7240  there  was  a  gra\'e  anemia.  The  heart  was  enlarged,  and  a 
diastolic  rumble  was  lieard.  A  very  diHicult  hysterectomy  was  ])erform(>d. 
The  patient  did  well  until  the  eighth  day,  when  she  manifested  a  slight  (lysj)nea. 
There  was  some  edema  of  the  face  and  legs,  and  a  rapid  and  weak  pulse.  The 
area  of  heart  dulness  was  considerably  larger  than  on  admission,  but  on  auscul- 
tation no  nuuTuurs  could  be  heard.  The  heart's  action  was  rajiid  and  approached 
the  fetal  type.  She  was  given  liquid  diet,  Epsom  salts,  cream  of  tartar  water, 
and  tincture  of  digitalis.     She  was  discharged  in  excellent  condition. 

In  Case  10164  what  aj)i)eared  to  be  a  pseudo-angina  developed  on  the  sixteenth 
day.  The  pulse  became  rapid,  small,  and  weak,  and  there  was  considerable 
precordial  pain.     The  attack  lasted  only  a  few  hours. 


COMPLICATIONS    I^OLLUWI.XG    ABJ)(),M1\AL    HVSTKKo.M YU.MKCTU.M Y.  001 

In  Case  12764  an  attack  of  syncope  occuitccI  on  the  third  day.  It  was  thoup;ht 
to  be  hysterical  in  character. 

In  Case  12696  faintiii,u'  occurred  on  tlie  second  day  (hirinu'  the  removal  of  a 
pelvic  drain. 

Nervous  Phenomena. — In  a  few  of  the  cases  the  patients  manifested  marked 
mental  depression  or  excessive  ner\'ousness  prior  to  operation,  but  after  removal 
of  the  uterus  these  phenomena  usuallj'  disaj)peared.  .Marked  nervous  symptoms 
following  hysteromyomectomy  are  rare.     They  are  divisible  into  two  main  groups: 

1.  Nervous  symptoms  a])])arently  dependent  upon  local  causes. 

2.  Nervous  symptoms  without  any  definite  assignable  cause. 
Nervous    Symptoms    Dependent    upon    Local    Causes. — 

In  Case  2070  a  simple  hysteromyomectomy  was  performed.  The  patient,  a  white 
woman,  aged  thirty-four,  did  well  until  the  third  day,  when  her  pallor  became 
more  marked;  the  pulse  rose  to  130,  and  the  temperature  to  102.4°  F.  There 
were  al)dominal  distention  and  restlessness.  The  ])atient  was  delirious  and 
nauseated,  but  on  the  seventh  day  a  decided  improvement  was  noted,  and  she 
made  a  good  recovery.  In  this  case  there  was  probably  intestinal  atony  or  a 
partial  obstruction,  with  absorption  from  the  stagnant  intestinal  contents. 

Nervous  S  y  in  p  t  o  m  s  without  any  Assignable  Cause  . — 
On  p.  547  it  was  noted  that  in  Cases  2710,  78S6,  and  8259,  marked  hysterical 
manifestations  developed  after  an  abdominal  myomectomy.  In  Cases  3449, 
3535,  and  3918  intense  nervousness  followed  the  abdominal  hysteromyomectomy. 

In  Case  2806  the  nervousness  was  so  severe  that  it  at  times  bordered  on 
delirium. 

Hallucinations  . — In  Case  11294,  the  patient,  aged  fifty,  white, 
had  a  definite  systolic  inunnur  at  the  apex.  As  soon  as  the  abdomen  was  o))ened, 
the  condition  became  precarious,  and  a  speedy  hysterectoin}-  was  imj)erative. 
The  patient  lost  a  considerable  amount  of  blood  and  was  nuich  shocked  after 
operation. 

On  the  fourth  da}'  she  began  to  ha\'e  hallucinations.  These  gradually  in- 
creased in  intensity  until  she  became  practically  insane.  Her  tem|)erature 
nevcn'  I'ose  above   100.5°  l'\,  and  her  general  condilion  was  good. 

On  the  fourteenth  day  after  operation  she  was  ti'ansfei'red  to  the  isolation 
ward.  Eleven  days  later  hei'  me!ital  condition  was  again  clear,  and  she  was  dis- 
charged ap|)arently  well.  Ten  months  later  her  |)hysician  reported  that  she 
was  p(>rfectly  well. 

This  ])atient  was  naturally  hysterical,  exceedingly  dexout .  hypersensitix'e.  and 
petulant.  The  loss  of  mental  control  was  in  no  wa\'  due  to  an  intoxication,  l)ut 
must  be  at  t  ri  but  ed  to  a  weak  II  lent  a  Iha  I  a  lice. 

Acute  .Mania.  In  Case  77()3  an  abdominal  hysterectomy  was  per- 
formed for  a  myoiiialous  utei'us  of  moderate  size.  Prior  to  operation  the 
patient,  a  white  woman,  aged  twenty-nine,  had  hail  gical  dilliciilty  in  kee])ing 
her  mind   on    the   suhiect     under    consideration,    and    liaxc   irrational    answers. 


662  MVOMATA    OF    THK    UTERUS. 

After  operation  she  eoniplained  a  great  deal  and  showed  hysterical  symptoms. 
On  the  sixtli  day  restraint  was  neeessaiy.  Dr.  Henry  M.  Hurd  saw  her  in  con- 
sultation and  diagnosed  acute  mania.  For  some  days  after  this  she  voided  and 
defecated  unconsciously,  and  as  a  result  a  very  extensive  bcd-.sore  develo})ed,  not- 
withstanding all  the  precautions  exercised.  She  also  developed  an  intense 
nephritis.  She  was  placed  in  a  continuous  bath,  and  gradually  improved  mentally 
and  i)hysically.  During  convalescence  she  fully  appreciated  her  condition,  and 
referred  to  the  periods  of  excitement  as  ''  bad  dreams."  When  discharged  on  the 
forty-fourth  day,  she  seemed  ([uite  rational. 

In  this  case  also  there  was  a  lack  of  mental  poise  before  operation.  We  have 
seen  patients  go  violently  insane  after  minor  operations,  such  as  perineal  repair, 
and  it  is  rather  remarkable  that  we  have  encountered  so  few  postoperative 
mental  disturbances  in  such  a  large  number  of  severe  abdominal  operations  when 
the  ]iatient's  reser^■('  force  is  so  fully  taxed. 

Suppuration  of  the  Abdominal  Wound. — Infection  of  the  alxlominal  wall  may 
be  limited  to  a  small  area  or  may  involve  the  entire  length  of  the  incision.  In 
some  cases  it  is  superficial;  in  a  few  it  involves  the  entire  adipose  tissue  and  ex- 
tends to  the  fascia.     It  is  more  ])rone  to  occur  in  stout  than  in  thin  individuals. 

In  some  cases,  in  addition  to  a  myomatous  uterus,  there  are  pus-tubes  or 
a  jx'lvic  abscess.  In  othei'  instances  a  sul)mucous  myoma  has  commenced  to 
ulcerate,  or  there  is  an  endometritis.  In  all  such  cases  there  is  a  danger  of  in- 
fection of  the  abdominal  wall  from  the  already  existing  pelvic  focus.  To  avoid 
such  infection  the  abdominal  incision  is  cai'efully  protected  with  gauze,  and  the 
instruments  that  have  been  employed  in  the  ])elvis  are  discarded  during  the 
closure  of  the  abdominal  incision. 

Breaking  down  of  the  incision  is  in  some  cases  undoubtedly  due  to  injury 
of  the  tissues  by  strong  ti'action  with  the  reti'actors,  too  small  an  abdominal 
incision  having  been  made.  Our  experience  coincides  with  that  of  other  clinics 
in  that  we  occasionally  have  an  incision  break  down  when  we  can  find  no  adequate 
reason  for  the  infection. 

On  ]).  673  a  case  is  reported  in  which,  on  the  fifth  day,  the  entire  abdominal 
incision  gave  way  and  the  omentum  was  exposcHl.  The  patient  died  a  few  hours 
later. 

Bed-sore.  —In  Case  7703,  after  renioN'al  of  the  uterus,  the  patient  developed 
acute  mania  on  the  sixth  day  and  restraint  was  necessary.  She  subseciuently 
voided  and  defecated  unconsciously,  and  as  a  result  an  extensive  bed-sore  de- 
veloped.    She  finally  made  a  good  recovery. 

Pelvic  Infection. — In  Chapter  X\TII  it  is  recorded  that  in  many  of  our  cases  the 
tubes  and  ovaries  were  the  seat  of  an  acute  or  chronic  inflammation,  and  it  is 
little  wonder  that,  after  a  .supravaginal  hysterectomy,  there  should  occasionally 
l)e  a  subsequent  pelvic  accunuilation.  In  the  greater  nund)er  of  these  cases  we 
guai'd  against  a  subs(H|uent  pelvic  abscess  by  di-aining  thi'ough  the  vagina  before 
closing  the  abdomen. 

We  shall  here  consider  oidv  those  cases  in  which  no  e\"i(lence  of  a  recent  in- 


COMPLICATIONS    FOLLOWING    ABDOMINAL    H VSTEROMYOMECTOMY. 


663 


fection  was  noted  at  the  time  of  opc^nition.  Jii  all  these  cases  it  is,  of  course, 
necessary  to  cut  across  the  cervix,  and  if,  ])erchancc,  the  uterine  cavity  is  infected, 
there  is  great  danger  that  the  cervical  stump  or  the  surrouncHiig  jx'lvic  tissue  will 
become  implicated.  Again,  if  a  myoma  extends  far  out  in  the  broad  ligament 
and  impinges  on  the  lower  pelvic  wall,  it  is  at  times  difhcult  completely  to  obliter- 
ate the  resultant  cavity,  and  if  there  is  any  oozing  into  this  cavity,  the  contents 
are  prone  to  become  infected.  Such  a  condition  existed  in  Case  5093,  and  it  was 
subsequently  necessary  to  drain  the  abscess  through  the  vagina.  In  Case  5359 
a  myoma  in  the  left  broad  ligament  was  shelled  out :  an  abscess  developed  in  the 
broad  ligament  and  oj)ened  into  the  bladder.     This  case  is  described  on  p.  553. 


CASES  OF  PELVIC  INFECTION  FOLLOWING  ABDOMINAL  IIYSTEPvOMYOMKCTONn' 


Gvx.  No. 

HiGHKST 

Temp. 
101.0° 

3614 

Diffuse      myomatous 

Inflammat  i  o  n 

Cervix           di- 

Recovery. 

thickening  of    uter- 

of      cervical 

lated;  70  c.c. 

1 

ine    wall.         Septic 

.stump. 

of     pus     es- 

temperature. 

caped    ( Figs. 
387and3S8). 

4193 

Large,     densely     ad- 

105.0° 

Inflammatory 

No    operation. 

Kxudategrad- 

herent     myomatous 

exudate      on 

ually  disap- 

uterus.   Septic  tem- 

right side  of 

peared. 

perature    noted    on 

pelvis. 

twentieth  day. 

o093 

Myomatous        uterus 

101.2° 

Pelvic  abscess. 

Opened        per 

Patient     per- 

size of  a  six  months' 

vaginam     on 

fectly     well 

pregnancy.     Tumor 

twenty- sixth 

eleven  years 

spread    out    in    left 

day. 

later. 

broad  ligament.  Mild 

septic  temperature. 

6030 

Uterus  about  11  cm. 

102.0° 

Encysted    pel- 

Opened        per 

Recovery. 

in  diameter.       Cer- 

vic      perito- 

vaginam     on 

vical  myoma  shelletl 

nitis. 

f  ou  rt  ecu  t  h 

out.    Septic  temper- 

day. 

ature. 

6039 

Uterus     extended     3 

103.5° 

Inflammatory 

Opened         }ht 

Recovery. 

cm.    above    umbili- 

mass, 4.5  cm. 

vaginam      on 

cus.      Hroad  cervix. 

in    diameter, 
to      left       ol 
cervix. 

f  ou  rt  ec  n  1  li 
ilay. 

7237 

Densely  adherent  niy- 

103.6° 

Abscess  in  cer- 

Cervix dilated; 

Reco\  cry. 

1     omatous  uterus.  .\d- 

vical    stuin|> 

90  c.c.  of  pus 

nexa   unusually  ad- 

escape d 

herent. 

through     ex- 
ternal OS. 

10555 

Myomatous       uterus; 

101. 0° 

On    eiglitecniii 

No  ()|)erat  ion. 

Di^appea  red 

subperitoneal     nod- 

(Imv    indura- 

in ten  days 

ule   10  cm.       Adhe- 

tion on  riglit 

after        fre- 

sions;       slight      te;ir 

side  of  pelvis, 

(|U('nt       use 

in     outer     coat      ol 

e  X  t  e  n  ding 

of              hot 

rcctuin. 

from     cer\i\ 
to  pel\ic\\;dl. 
Tenderness. 

douches. 

San.  No.  1944 

MyoiiiMtoiis       ulerii--, 
Sx  12  X  12  cm. 

100.1^' 

Til  ic  k  e  ti  i  ng 
around     cer- 

.\()  ii|)('rat  ion. 

Kcco\(Ty. 

vix    for   thir- 
teen (lavs. 


664 


MYOMATA    OF    THK    UTERUS. 


Treatment. — In  some  cases  it  is  marvelous  how  the  induration  will 
literally  fade  away  under  frequent  hot  douches.  This  was  well  exemplified  in 
Cases  4198  and  lOooo.     From  the  surgeon's  point  of  view  these  cases  should  be 

divided  into  two  main  groups: 

1.  Infection  rmiilcd  to  the  cervix. 

2.  Infection  invoh-ing  the  hroad  liga- 
ment or  extending  to  Douglas'  pouch. 

Infection  Limit  e  d  to  the 
C  e  r  V  i  X  . — If  the  area  of  induration  is  in 
the  cei-vix  and  not  marked  in  the  broad 
ligament,  it  is  ])robable  that  the  infection 
has  come  from    the  cervical   canal,   as   in 

Fio.  .387.— A  Purulent  Accumulation  in  thk        Fig.   387.       lu    SUch  a   CaSC  it  is  Ouly    UeCeS- 
Ckrvic.l   Stump    Following     Suprav.v.u-  ^^^  carcfullv  dilate  the    CCrvix  and    pUS 

NAL  Hysterectomy.  -       j  ^  i 

Gyn.  No.  3614.     After  supnivugiiial  removal        CSCapCS      (Fig.       388).         This     Ulcthod     WES 

of  an   adherent    myomatous   "tems   the   patient        .^^l,      |^.^|   J,^   (^.^g^g   ^QU  and   7237. 

had  a  temperature    rangmg   from    100     to    101"  ' 

for  several  days.     On  the  fifteenth  day  the  cer-  Drainage  of  DoUglas'  pOUch  lu   either  of 

vix  was  dilated  (Fig.  .388)    and  about  70  c.c.  of  ,  i   i   i  i  c  i-i.i.i 

pus  escaped.      The   abscess   developed    between        thcSC  CaSCS  WOUld  liaVC    bCCn  Ot  llttic  Or  HO 

the    cervical    stump    and    the    overlying    pelvic        vdue  * 

peritoneum.      (After  Thomas  S.  CuUen.) 

Infection  Involving  the 
B  r  o  a  d  L  i  g  a  m  e  ii  t  or  Douglas'  S  a  c  . — In  these  cases  vaginal 
drainage,  as  described  on  p.  ()23,  should  be  carried  out. 

Multiple  Abscesses. — (Case  H.)  The  })atient  was  admitted  to  the  Church 
Home  and  Infirmary  in  June,  1903.  On 
opening  the  alxlomen  one  of  us  (Cullen) 
found  a  ghjlmlar  myomatous  uterus 
wedged  in  the  ])elvis.  It  was  removed  in  ] 
the  usual  way  from  left  to  right,  but  with 
considerable  difficulty  on  account  of  the 
dense  jidhesions  and  the  thickened  and 
adhei-eiit  Fall()])iaii  tubes.  At  tlle  time  of 
operation  the  j)atient  had  a  very  bad  va- 
ginal discharge. 

Shortly  after  operation  the  temperature 

rose,  and  on  the    elcN'enth   day    it    reached 

103°  F.     On   ]X'lvic  examination  a  definite 

iiKhirated   mass,  about    8  cm.    in   diameter, 

was  felt    on    the    left    side.     .\    small    trans\'erse    incision    was   made    through 

the  vaginal    mucosa,   just    behind   the   cer\'ix,   and    blunt    dissection   continued 

upward    and   to    the   left    with    the    finger.      A    blunt    uterine   dilator  was   in- 

*  Infection  Limited  to  the  Cervix. — In  Case  1499.  during  convalescence  the  patient  had  several 
attacks  of  pain  in  the  lower  abdomen,  with  a  rise  in  temperature.  Following  this  there  was  a 
profuse  discharge  of  pus  from  the  vagina.  There  had  evidently  Ix-cii  a  purulent  accumidation 
in  or  near  the  cervical  canal. 


Fic.  388. —  Dii.ATiNi;  a  Cervix  to  Re.move  an 
Accumulation  of  Pus  Between  the 
Cervical  Stu.mp  .\nd  the  Pelvic  Peri- 
toneum.    (.\fter  Thomas  S.  CuUen.) 


COMPLICATION'S    FOLLOWING    AUI)()ML\AL    II  VSTKIJO.M  V().MK(  TOM  V.  6(l5 

troduccd,  and  a  considerable  amount  of  bloody  fluid  and  pus  csca])!')!.  During 
the  afternoon  there  was  a  good  deal  of  oozing,  and  when  I  returned  to  the  citv. 
after  a  few  hours'  absence,  the  jAilse  was  1.30  and  tht'  ])atient  had  lost  a  gi-eat  deal 
of  blood.  She  was  immediately  anesthetized.  The  oozing  was  fcnmd  to  come 
from  the  left  side  of  the  cervix,  ju.st  at  the  normal  site  of  the  uterine  vessels. 
It  was  impossible  to  check  the  bleeding  without  j)la('ing  ligatures  in  verv  close 
proximity  to  the  ureter.  The  abscess  cavity  was  accordingly  quickly  packed 
with  iodoform  gauze  which  was  se^ATi  in  place  with  catgut,  the  vaginal  walls 
being  drawn  over  it  as  far  as  possible.  The  pulse  after  operation  varied  from 
150  to  160.  Saline  infusions  and  strychnin  were  employed.  ( )n  I  hi'  loHowing 
day  the  pulse  had  droppetl  to  120  and  was  of  good  volume.  A  few  da}-s  later 
an  area  of  induration  was  noted  just  posterior  to  the  anus.  This  gradually  in- 
creased in  size.  The  overlying  skin,  although  pale,  was  somewhat  edematous. 
An  incision  was  made,  and  a  pocket  of  pus  containing  at  least  100  c.c.  was  found 
deep  in  the  adipose  tissue.  The  temperature  steadily  drojiped  after  the  abscess 
had  been  opened  and  soon  became  normal. 

A  few  days  later  there  was  pain  in  the  right  forearm.  The  jtatient  had 
frequently  had  rheumatism,  and  her  husband,  a  physician,  thought  that  the  pain 
was  similar  to  that  she  had  previously  experienced.  We  were,  however,  sus- 
picious of  an  abscess.  The  temperature  again  rose.  We  made  an  incision  in 
the  right  forearm  and  let  out  a  considerable  (juantity  of  pus.  Four  years  later 
the  patient  was  in  excellent  condition.  We  had  done  our  best  i)rior  to  operation 
to  check  the  offensive  vaginal  discharge,  but  had  be(»n  unable  to  do  so.  The 
original  infection  noted  in  the  pelvis  at  the  time  of  operation  and  during  the 
hysterectomy  had  evidently  become  disseminated. 

Phlebitis. — In  the  accompanying  table  are  the  records  of  27  cases  of  phlel)itis 
following  abdominal  hysteromyomectomy.  In  17  the  left  leg  was  involved: 
in  6,  the  right  leg,  and  in  .3  there  was  thrombosis  on  both  sides.  In  one  case  the 
records  are  not  cleai'. 

In  some  cases  only  the  saphenous  \'ein  was  inq^licated;  in  others  there,'  was 
definite  thrombosis  in  the  femoral  \'ein. 

In  Case  49.55  the  myomatous  uterus  was  densely  adherent .  Dui'ing  convales- 
cence the  abdominal  incision  broke  down  almost  completely,  and  on  (he  sixteenth 
day  a  very  severe  j)hlebitis  de\('loped  in  both  legs.  The  j)atient  finally  made  a 
good  recovery. 

In  Case  12154  the  myomatous  uteinis  extended  nboxc  the  umbilicus  ;nid 
was  \'ery  adherent.  Phlebitis  (lexclojx'd  in  the  Idl  leg  on  ihc  ninlh  day: 
in  the  I'ight  on  the  Iwenly-third  day.     The  ])atieiil  made  ;i  good  I'ecoxcry. 

In  two  of  these  cases  I  hi'onibosis  had  been  not  rd  jtr'nir  lo  opei';it  ion. 

In  Case  75()0  a  phlebitis  ha<l  (lc\clo))cd  in  llie  Idl  leg  al'lcr  ihe  birlh  of  the 
second  child.  During  convalescence,  nfl  cr  ii'iiio\;il  of  a  small  luyoiualous  ulcrus 
and  the  re])aii"  of  a  lefl  ureteroxnginal  llslula,  phlebitis  de\-elo|)ed  in  the  i'ight 
leg. 


666 


MYOMATA    OF    THE    UTERUS. 


In  Case  12199  an  ovarian  tumor  had  been  removed  eight  year.s  before  ad- 
mission, and  during  convalescence  there  had  been  thrombosis  of  both  femoral 
veins.  After  the  removal,  by  abdominal  section,  of  a  myomatous  uterus  the 
size  of  that  of  a  four  months'  pregnancy,  thrombosis  in  l)oth  femoral  veins  again 
(level()i)ed. 

PH  I.I'.IUriS   F(  )LL(  )WIXG  HYSTEROMYOMECTOMY. 


Cask  No. 


1666 

209S 


344.") 
4369 
4372 

4617 


Size  of  Uterus. 

HEMO.-.I.OBIN.         Day  AFTER 

Operatio.n'. 

Vein  Thro.m- 

BOSED. 

Remark.s. 

Nearly  filled  ab- 

16th 

Left  saphenous 

Swelling    of    glands    in 

domen. 

vein. 

groin.  Edema  of  foot 
and  leg. 

Abdomen        liidf 

.\neniic.                    22(1 

In  left  leg  and 

Pus  in  uterine  cavity  at 

filled. 

thigh. 

operation;  evidently 
slight  infection  after 
operation.  Temper- 
ature 99.6°  to  103.6°. 

Large. 

Reached    uinl)ili- 

loth 

\'erv"anemic.           16th 

lOtii 

In  left  leg. 
Left  .saphenous. 
In  left  leg. 

\'ery  difficult  operation. 

cus. 
Reached    uinhili- 

In  right  leg. 

Discharge  of  foul-smell- 

CII.S. 

ing  pus  from  vagina 
for  a   long  time  after 

Filled  large  part 

1.5th 

Right    femoral 

operation. 
Pleurisy   on    right   side 

of  alxlomen. 

vein. 

during  convalescence. 

4902 

Filled  large  part 

of  alxlomen. 

4903 

Filled  two-thirds 

of  abdomen. 

49.5.5 

Moderate       size, 

densely         ad- 

herent. 

.5766 

.Size  of  six  and  one- 

half        months' 

pregnancy. 

6372 

Fills  pelvis. 

nth 

16th 
20th 


691.5 
7.569 

Size      of      eight 
months'     preg- 
nancy. 

.Small.      (.\deno- 
myoma.) 

23d 

832 1 

Fills  pelvis. 

14th 

10199 

(Small          pehic 

9.5 

per  cent. 

.Stli 

]()211 
10229 

myoma . ) 

Contained     myo- 
ma about  7  cm. 
in  diameter. 

Reached   uini)ili- 

70 
7.5 

per  cent. 
j)er  cent. 

lOtli 
22d 

10281 

cus. 
Half-way  to  um- 
bilicus. 

77 

per  cent. 

10th 

10323 
103.57 

Half-way  to  um- 
bilicus. 

Reached  to  with- 
in 4  cm.  of  um- 
bilicus. 

49 

per  cent. 

.5th 
6th 

In  right  leg. 

Severe  in  both 
legs. 

Left  internal 
saphenous. 

Slight  phlebi- 
tis in  left 
groin,  thigh, 
leg.  and  foot. 

In  left  lesr. 


.\l)ilominal  incision 

broke     down     almost 
completely. 


Desperate   operation. 


In  right  leg.  Had    had    phlebitis    in 

left  leg  after  liirth  ot 
second  child. 
.*>liglit  swelling 
in  lower  right  i 
leg.  ^       ' 

Lett  saphenous.   Temperature     rose     to 
102°  on   twelfth   day. 
Right      saphe- 
nous. 


Right      saphe- 
nous. 
Left  femoral. 


Left  rciuornl. 
Left  femoral. 


Temperature  100-103.-5° 
from  thirteenth  to 
twcntv-first  (lav. 


COMPLICATION'S    F0LL0\^■1^■G    ABDOMIXAL    H  VS'l'KHO.M  Vo.MKCToM  V.  i'iiu 

Phlebitis   Following  HysTEROMvoMEfTOMY. — {Contimied.) 


Cask  No. 
10778 
10875 

12154 
12199 


12811 
C.    H.    I. 

(W) 

C.    H.    I. 

(A) 


SiZK    OF     UtKULS.  HEMO.n.OIUN.        ,V^'*'    •^••'•'KR  ^EI^'     THROM- 

(JPKRATION.  B08ED. 


Rkmakks. 


Reaches  5  cm. 
above  umbili- 
cus. 

Several  small 
myomata;  bi- 
lateral ovari- 
an cysts. 

4  cm.  above  um- 
bilicus. 

Size  of  four  and 
one-half  months' 
pregnancy. 

Fills  pelvis. 
Size  of   four  and 

one-half  months' 

pregnancy. 
Fills  pelvis. 


60  per  cent. 


2Ist         i.cft  femoral. 
20th       Left  femoral. 


9th  1 

2;ki  / 


In  both  legs. 


Bt)tli  feinorals.     After  rcinoval  nf  ()\arian 
I     tumor  eiglit  years  be- 
I     fore  she  had  luul  phle- 
bitis on  both  sides. 
14th        Left  femoral. 
11th        Left  femoral. 


Few  days 
after  op- 
eration. 


In  Case  3492  symptoiii8  .suggestive  of  puliiiuiiary  enibolisni  (lcvcl()])c(l,  and 
subsequently  there  were  signs  of  phlebitis  in  both  legs  and  the  left  ai'iii.  On 
account  of  the  lack  of  clearness  in  the  diagnosis,  this  case  is  not  iueludcd  in  the 
tabulation. 

As  will  be  seen  from  the  table,  thrombosis  occurred  as  early  a.^  the  fifth 
day  and  as  late  as  the  twenty-third  day.  The  most  common  periotl  was  between 
the  tenth  and  the  twenty-third  days. 

In  Cases  2098,  4617,  and  4955  the  phlebitis  was  associated  with  infection,  and 
in  Case  4902  with  ])leurisy.  In  a  few  of  the  cases  faint  hemic  imirinuis  were  noted, 
but  in  only  one  case  (1032.3)  was  there  any  organic  lesion — a  mitral  insullicicncy. 

It  was  impossible  to  determine  the  cause  of  the  thrombosis  in  the  above  cases. 
It  seemed  to  develo])  in  certain  cases  irrespective  of  whether  the  tumors  were  hirge 
or  small,  free  or  adhei-ent ,  and  whether  infection  was  presenl  oi- not  nl  o|H'r:ition. 
It  is  particularly  interesting,  however,  to  note  that  the  greater  inimber  of  cases 
of  phlebitis  developed  in  four  isolated  and  distinct  jx-riods  in  the  histoiy  of  the 
hosi)ital.  For  instance,  the  table  shows  that  they  were  most  pi'e\alent  in  the 
fifth,  seventh,  eleventh,  and  thirteenth  thousands.      .Ml  of  the  patients  i-ecovered. 

For  j)hlebitis  following  abdominal  niN'oniectomies  see  p.  o.").").  l-'or  those 
cases  complicating  vaginal  myomectomy  see  ]>.  ,")7!l.  ami  tho.se  occurring Mn 
the  fatal  cases,  p.  675. 

Treat  ment  .  -The  leg  was  wrapiied  in  absorbent  cotton  and  ele\'ated. 
and  every  precaution  taken  to  aNoid  much  ino\-en)enl  of  the  ))ai1.  .Massage, 
of  course,  was  prohibited. 

Pleurisy. — Three  of  our  patients  showed  definite  sigiL-^  of  pleurisy  after  the 
operation. 


668  .MYU.MATA    OF   THE    UTERUS. 

In  Case  3492  a  wliitc  woman,  aged  thirty-nine,  had  a  myomatous  uterus 
filhng  the  lower  alxlonien.  For  eight  days  after  oi)cration  the  temperature 
varied  from  99°  to  101°  F.  It  then  rose  to  103.5°,  and  a  thy  {pleurisy  was  de- 
tected. Suddenly,  on  the  eighteenth  day,  the  patient  had  a  fainting  spell  and 
showed  symptoms  suggestive  of  intra-abdominal  hemorrhage.  None  was. 
however,  found,  and  the  gcnci'al  consensus  of  opinion  afterward  was  that  the 
patient  had  had  a  pulnionar}-  cmholism.  After  the  exploratory  section  the 
patient  developed  phlebitis  in  both  legs  and  tlie  left  arm.  She  finally  made  a 
good  recovery. 

In  Case  4902,  during  convalescence  after  removal  of  a  large  myomatous  uterus, 
a  dry  pleurisv  developed  on  the  right  side,  and  on  the  fifteenth  day  a  mild  phlebi- 
tis of  the  right  femoral  vein.     Recovery  was  otherwise  uneventful. 

In  Case  8294  the  patient  was  forty-five  years  of  age  and  white.  The  myo- 
matous uterus,  which  extended  3  cm.  above  the  umbilicus,  was  easily  removed. 
Gas  and  ether  anesthesia  was  employed.  The  same  evening  the  patient  com- 
plained of  ])ain  on  the  right  side.  Her  temjx'ratiu'e  was  101°  F..  and  a  distinct 
friction-rub  could  be  made  out  in  the  right  lower  axilla.  By  the  tenth  day  the 
temjjerature  had  reached  normal,  but  a  faint  rul)  could  still  be  heard. 

In  Cases  3492  and  4902  the  pleuris}'  may  possibly  ha\'e  aiisen  from  a  secondary 
infection.  In  Case  8294,  however,  it  came  on  too  early,  and  was  evidently  an 
entirely  inde))endent  process. 

Bronchitis. — In  three  in.stances  we  encountered  a  bronchial  inflammation 
during  convalescence.  In  Case  4022  the  uterus  filled  tlie  lower  abdomen  and 
the  bladder  was  displaced  ui)ward.  For  eleven  days  after  the  operation  the 
temperature  ranged  from  99°  to  101.2°  F.  On  the  twenty-first  day  it  rose  again, 
reaching  103.6°  F.  This  ri.se  was  appai-ently  due  to  a  bi'onchitis.  The  patient 
was  well  when  she  left  the  hospital. 

The  myomatous  uterus  in  Case  4894  reached  8  cm.  above  the  umbilicus. 
On  the  seventeenth  day  after  the  operation  the  temperature  rose  to  102°  F. 
A  hai'd.  indurated  mass  was  detected  in  the  ])elvis.  and  the  patient  had  a  definite 
bronchitis.  The  temperature  soon  fell,  the  bronchitis  disappeareil.  and  the 
patient  made  a  good  recovery. 

In  Case  12738  a  myomatous  uterus  filled  three-fourths  of  the  abdomen. 
Hysterectomy  was  rendered  difficult  on  account  of  intestinal  adhesions.  On  the 
second  day  the  patient  had  a  temperature  of  103°  F.,  due  to  an  acute  bronchitis. 
She  was  discharged  well  twenty-eight  days  after  operation. 

^^  hethei'  the  bi'onchitis  in  the  last  case  was  due  to  the  anesthetic  or  was  merely 
an  accidental  accompaniment  we  are  unal)le  to  .say. 

Bronchopneumonia. — In  the  following  table  are  given  the  cases  in  which 
a  bronchopneumonia  complicated  convalescence.  In  two  of  the  cases  the  oper- 
ation had  been  very  difficult,  and  in  a  third  the  patient's  heart  was  dilated  and 
the  hemoglobin  was  only  35  per  cent.  In  the  two  remaining  cases  the  oper- 
ation was  relatively  easy.     All  these  patients  recovered. 


COMPLICATIONS    FOLLOWIXd    ABIX  ).MIXAL    HYSTKHC  )MYO.M]:CT(  )MY. 


669 


In  Case  11  ISO   there  was  a   l)ronch()])iiciini()nia   jtrohably  seeondarv  to    a 
pulnioiiaiy  abscess.     This  ease  is  ineiitioiicd  on  p.  (iSl. 

CASES    OF    BRONCHOPNEUMONIA    AFTl'H    AHDOMINAL    liYSTERO.MYOMECTO.MY. 


Case  No. 

Operation. 

Bronchopneumonia. 

Result. 

6792 

Difficult;    severe  hemorrhage. 

Bronchopneumonia      and 

right  pleurisy. 

Recovery. 

10204 

Easy. 

Developed  on  eighteenth 
day. 

Recoverj\ 

10287 

Easy. 

Developeil  on  sixth  dav. 

Recoverv. 

10426 

Heart    dilated;     heniojilobin. 
35  per  cent.    Operation  diffi- 
cult on  account  of  intestinal 
adhesions.     Hemoglobin,  60 
per  cent. 

Developed  on  second  day. 

Recovery. 

11869 

Easy;    double  pyosalpinx. 

Bronchopneumonia. 

Recovery. 

Pneumonia  after  Hysteromyomectomy. — Tn  addition  to  the  two  cases  in 
which  recovery  took  phice  are  Cases  7381,  in  which  the  patient  (hed  of  lobar 
pneumonia  on  the  seventeenth  day,  and  Case  6997,  in  which  an  intercurrent 
double  basal  pneumonia  developed  during  convalescence  and  death  from  dysen- 
tery took  place  in  the  eleventh  week.     These  cases  are  recorded  on  j).  681. 


Case  No. 

Operation. 

Part  Involved. 

Day  ,\fter       Highest  Tem- 
Operation.           perature. 

Result. 

934 
12194 

Easy.           Upper  left  lobe. 
Easy.           Posterior     part     of 
right  lower  lobe. 

3d                     104.8° 
17th                 100° 

Recovery. 
Recover3^ 

Pulmonary  Abscess. — In  Case  6933  the  patient  was  thirty-nine  years  old  ami 
wliite.  The  greatly  enlarged  myomatous  uterus  was  removed  without  difiicuhy. 
On  the  fifteenth  day  the  patient  complained  of  pain  at  the  lower  angle  of  the 
scapula  on  the  right  side.  On  the  seventeenth  day  there  was  an  clex'ation  of  tem- 
perature and  ])ulse,  slight  moaning  on  deep  ins])iration,  and  a  congh.  On 
the  twenty-eighth  day  she  coughed  forcibly  onc(\  and  ihcic  was  an  innncdiatc 
escape  of  sevei'al  ounces  of  jjui'ulcnl  material  which  consisted  of  pus-cells,  'i'lie 
patient  was  much  relieved  after  expectorating  the  fhiid.  She  h'ft  the  hospital 
two  days  later,  still  weak,  l)ut  free  from  pain. 

For  pulmonary  abscess  occui'ring  in  the  fatal  cases  see  |).  682. 

Symptoms  Suggesting  Abdominal  Hemorrhage,  but  Probably  Due  to  a  Pul- 
monary Embolus. — In  Case  .'MO'J  the  ])alieiit,  aired  thirty-nine,  white,  had 
])r()fuse  uterine  bleeding  due  to  a  submucous  niNoina.  10  cm.  in  di.aiuetei".  The 
multinodular  myomatous  uterus  was  i-eniox'ed  ])er  abdomen,  ller  tempei'atui'e 
varied  from  99°  to  101°  V.  toi'  eight  days,  when  it  rose  to  103.")°  1*\  and  a  "dry 
]i)eurisy"  was  dectecteil.     Suddenly,  on  the  eighteenth  day,  she  had  a  fainting 


670  ^lYOMATA    OF   THK    ITERUS. 

spell.  The  pulse  rose  to  130,  the  respirations  became  rapid,  the  hands  were 
clammy,  and  the  ])atient  presented  a  typical  picture  of  hemorrhage.  The 
abdomen  was  at  once  opened,  Init  the  area  of  ojM'ration  was  in  a  ])erfect  condition. 
The  t('m])erature  vai-jcd  from  99°  to  101..')°  I'\  for  the  next  ten  days,  when  it  again 
rose  to  10o.2°  with  .symptoms  of  phlebitis  in  both  legs  and  the  left  arm.  She 
was  discharged  well.  Pulmonary  embolism  was  probably  the  cause  of  the  sudden 
collapse. 

The  fatal  cases  of  {juliiioiiary  embolism  arc  described  on  ]).  680. 

Complications  following  Vaginal  Hysterectomy. 

Transitory  Lack  of  Recognition. — In  Case  8951  a  small  myomatous  uterus 
was  bisected  and  removed  tln-ough  the  vagina.  The  patient,  aged  forty-eight, 
recovered  slowly  on  account  of  weakness  and  anemia. 

On  the  twenty-second  day  she  was  irrational,  had  tingling  pains  in  the  right 
arm,  and  did  not  recognize  the  nurses.  This  condition  lasted  for  a  day  or  two 
and  gradually  disap})eared.  ^^'hen  discharged,  she  was  in  good  condition  ex- 
cept for  the  weakness. 

Tn  this  case  we  can  only  surmise  as  to  the  sudden  and  temporary  clouding 
of  the  intellect. 

Delusional  Insanity. — In  Case  1852,  the  })atient,  aged  forty-seven,  white,  had 
a  small  retroflexed  adherent  myomatous  uterus  removed  through  the  vagina. 
Two  and  a  half  weeks  later  a  strangulated  inguinal  hernia  was  reduced  and  the 
opening  closed. 

After  the  operation  the  ])atient  developed  delusional  insanity.  Before 
operation  she  was  weak  mentally. 


CHAPTKPv  XXW. 

RESULTS  OF  OPERATIONS  FOR  UTERINE  MYOMATA. 

Our  material  consists  of  the  patients  operated  upon  at  the  .Johns  Ilojjkius 
Hospital  u})  to  July  I,  1 '.)()(),  those  coming  under  the  care  of  Howard  A.  Kelly 
at  his  sanatorium,  and  those  o})erated  upon  by  Thomas  S.  Cullen  at  the  Church 
Home  and  Infirmary,  the  Cambridge  (Md.)  Hospital,  and  a  few  at  the  Emerg- 
ency Hospital,  l"'re(lei'i('k,  Md. 

Cases  admitted  to  the  gynecological  (le])ai1ineiit  of   the  .lohus  Hopkins 
Hospital   fi'om   the  o])ening  of    the   hospital    in    1SS<),   to  .lulv    1. 

1006 "  ...1207 

Sanitarium  (  Kelly) 64 

Chiu'ch  Home  and  Infirmary,  Cambridge,  and  Frederick  (Cullen)  ....     97 

Total 1428* 

In  55  of  the  cases  no  radical  operation  was  attempted  on  account  of  the 
weakened  condition,  or  on  account  of  refusal  on  the  part  of  the  patient.  In  some 
cases  a  simple  exploratory  operation  was  done,  and  the  hopeless  character  of  the 
case  determined.     In  some  cases  no  operation  was  deemed  advisable. 

Among  these  55  cases  21  deaths  occurred  in  the  hospital. 

In  7  cases  death  followed  an  exploratory  abdominal  section. 

In  2  cases  death  followed  a  vaginal  section. 

In  1  case  death  followed  a  combined  vaginal  and  abdominal  exj)loration. 

In  11  cases  no  operation  was  performed. 

Total,    21    cases. 

When  we  deduct  those  cases  in  which  no  radical  operation  could  ])e  performed. 
we  still  have  1373, t  in  each  of  which  one  or  more  uterine  myomata  were  renio\-ed. 

IMMEDIATE  RESULTS  IN  OPERATIONS  FOR  UTERINE  MYOMATA. + 

Abdominal  inyomectorny.  ..  .  296  cases,    280  recoveries,  16  deaths.  Deafli-rate,    .">.  1     i)erct'iit. 

Vaginal  myomectomy 84  "  79           "             5  "  "              6 

Abdominal    hysteromyomec- 

tomy 901  "  S,")I           "           .'>()  '•  ■•               .-)..-,.-) 

Abdominal    hysteromyomec- 

tomy     with     bisection     of 

uterus 68  "  (iO           "             8  "  "            11. 7(1  •       •• 

Vaginal  hysteromynmoctorny  24  "  24           "             0  "  "              .... 

i;57.S  1294  79  r^.7r^  + 

*In  addition  to  liiis  nuinixT  (iiiitc  a  iiuinix'i'  ol  nl  iicr  cases  arc  mentioned  in  tiic  l)()ok.  'i'liese 
are  all  interesting,  and  either  occurred  since  July  1,  19()(),  or  have  been  o|)erated  u|)on  liy  others. 
Two  hundred  and  forty-.six  cases  entered  tlie.Ioims  IIo])l<ins  Hospital  iict  ween  July  1 ,  19(16.  an<l  .Ian. 
1,  1909,  tlius  making  a  total  ol'  1671  myoma  cases  th.it  lia\e  come  under  our  |)crsonal  observation. 

t  At  least  13  patients  were  admitted  to  the  hospital  more  than  once,  but  in  the  total  miml)er 
of  cases  only  the  first  hospital  Tuimber  was  considered.  Each  mimi)er  thus  stands  for  a  diffcnMit 
individual. 

JTlie  deatii-rate  in  the  last  two  and  a  half  years  has  been  less  than  one  per  cent,  (.see  p.  687). 

671 


672  MYO.MATA    OF    THE    ITERUS. 

In  the  remaining  55  cases,  no  radical  operation  was  performed. 

Of  these  patients,  10  (hed  as  the  I'esult  of  the  exploratory  operation. 

Eleven  died  iij)on  whom  no  operation  was  performed. 

From  the  above  table  we  see  that,  of  1373  patients  operated  upon,  1294 
recovered  and  79  died — an  average  death-rate  of  over  5.75  per  cent. 

Immediate  Results  in  Abdominal  Myomectomy  Cases. — Out  of  296  patients, 
280  recovered  and  16  died,  a  death-rate  of  5.4  per  cent.  Naturally,  abdominal 
myomectomy  is  pci'formetl  only  in  suitable  cases;  in  other  words,  in  cases  in 
which  there  is  a  strong  chance  of  preserving  a  normal  uterus.  Under  these 
circumstances  we  would  naturally  expect  a  lower  death-rate  than  in  the  group  of 
abdominal  hysteromyomectomies,  which  included  many  desperate  cases.  The 
rate  is  slightly  lower,  but  the  difference  is  less  than  one  might  expect.  We  are 
all  aware  of  the  fact  that  myomectomy  offends  nmch  more  chance  for  subsequent 
infection  than  does  hysteromyomectomy. 

Abdominal  myomectomy  is  considered  in  detail  in  Chapter  XXIX.  Here  also 
are  given  in  extenso  the  postoperative  complications,  the  causes  of  death  in  the 
fatal  cases,  and  a  list  of  the  ])atients  that  have  subsequently  borne  children. 

Immediate  Results  Following  Vaginal  Myomectomy. — From  the  tabulation 
it  is  seen  that  of  84  cases,  79  patients  recovered  and  5  died — a  death-rate  of  6 
percent.  In  Chapter  XXX  these  fatal  cases  are  recorded  in  detail,  and  it  will  be 
seen  that  in  4  out  of  thc^  5  cases  the  patients  were  in  a  desperate  condition  and 
opei'ation  ga\'('  the  only  hope  of  even  tempoi'ary  salvation.  In  only  one  case 
were  we  surprised  at  the  fatal  issue.  This  ])atient  had  a  small  submucous  myoma 
twisted  from  the  ulterior  of  the  uterus.  She  did  well  for  a  short  time,  and  then 
rapidly  grew  weaker  and  died.     This  case  is  described  in  detail  on  p.  580. 

Results  after  Abdominal  Hysteromyomectomies. — In  901  cases  an  abdominal 
hysteromyomectomy  was  ])erformed:  851  patients  recovered  and  50  died — a 
mortality  of  5.55  per  cent.  In  the  majority  of  the  cases  the  uterus  was  ampu- 
tated  thi'ough    the   cervix.     In   only  50  cases  was  a    j)anhysterectoniy  done. 

Causes  of  Death  following  Abdominal  Hysteromyomectomy. 

This  table  is  as  accurate  as  we  can  make  it.  l)ut  every  surgeon  will  realize 
that  there  arc  numci'ous  chances  for  error.  In  some  cas(\s  we  have  been  forced 
to  rely  on  the  posto))erativc  history  for  the  probable  cause  of  death,  no  autopsy 
having  been  granted.  In  other  cases  the  patients  died  of  peritonitis,  but  whether 
the  se])tic  factor  was  pj-imary  or  secondary  to  an  obstruction  it  was  difficult  to 
determine. 

Probable  cause : 

General  peritonitis  in 22  cases 

Intestinal  obstruction  in    5       " 

Shock  "     7       " 

Pulmonary  embolism    "     4       " 

Other  causes  "     12       " 

Total 50  cases 


RESULTS    OF    OPEHATIOXS    FOR    UTFRIXK    MYOMATA.  673 

Deaths  due  to  Peritonitis  Following  Abdominal  Hysteromyomectomy. — 
The  tabulation  of  deaths  due  to  peritonitis  after  al)dominal  hysteromyomectomy 
shows  that  in  quite  ti  nunil)er  of  cases  it  was  impossible  to  trace  the  source  of 
infection,  but  in  the  majority  the  operation  was  either  complicated  by  very 
dense  adhesions,  sometimes  leading  to  injury  of  the  bowel  during  the  operation, 
or  was  associated  with  an  infected  uterus,  a  suppurating  myoma  or  a  purulent 
collection  in  the  adnexa. 

In  Case  1767  death  seemed  to  be  due  to  separation  of  the  abdominal  wound. 
Removal  of  the  uterus,  which  reached  the  umbilicus  and  contained  thirty 
myomata,  was  difficult.  On  the  fifth  day  the  abdominal  incision  was  widely 
separated,  and  the  omentum  was  bulging  up  into  the  incision.  Studding  the 
margins  of  the  incision  were  little  foci  of  pus.  The  patient,  before  operation, 
had  many  sonorous  and  whistling  rales  and  severe  paroxysms  of  coughing  which 
continued  after  the  operation  and  may  have  been  the  cause  of  the  giving  way  of  the 
abdominal  sutures.  iShe  died  with  definite  signs  of  peritonitis  on  the  eighth  day. 
In  this  case  it  would  ha^'e  been  much  wiser  to  have  delayed  operation  until  the 
pulmonary  symptoms  had  entirely  subsided. 

Infection  from  a  sloughing  submucous  myoma  was  noted  in  Case  4609.  The 
uterus  was  the  size  of  that  of  a  five  months'  pregnancy.  Examination  of  the 
specimen  after  removal  showed,  in  addition  to  su])pentoneaI  and  interstitial 
mj^omata,  several  submucous  nodules.  The  largest  of  these  was  4  cm.  in  diam- 
eter, and  its  surface  had  been  converted  into  a  greenish-yellow  suppurating  tissue. 
The  uterine  mucosa  near  the  internal  os  was  hemorrhagic  and  covered  with 
necrotic  material  from  the  suppurating  myoma.  In  addition  to  the  compli- 
cations already  mentioned  the  urine  contained  albumin  and  casts.  In  this  case 
operation  was  delayed  for  eleven  days  in  the  hope  that  the  discharge  might  be 
lessened  and  the  abdominal  operation  rendered  less  dangerous,  but  the  di.s- 
charge  did  not  abate,  and  hysterectomy  was  undertaken. 

In  such  cases  the  operator  is  often  confronted,  on  the  one  liand.  by  the  abso- 
lute certainty  of  the  patient's  speedy  death  if  she  is  not  rene\'ed.  and.  on  the  other 
hand,  by  the  great  risk  of  infection  if  any  operative  interference  is  attempted. 

In  Case  7158  the  fatal  ])erit()nitis  was  due  to  a  sloughing  subperitoiu^al  myoma. 
The  patient  at  operation  was  markedly  emaciated  and  was  in  a  most  critical 
condition.  Her  pulse  varied  from  120  to  loO.  The  tumor  was  about  the  size 
of  a  five  months'  pregnant  uterus.  When  the  hand  was  passed  around  to  the 
right  of  the  uml)ilicus,  several  ounces  of  thick  green  fetid  ]ius  which  had  a  gailicky 
odor  escaped.  It  was  (|iiickly  s]X)nged  uj).  On  I'ciiioxal  of  the  uterus  t  his  large 
abscess  was  found  to  be  (hie  lo  ( lie  hreakiiig-dowu  of  a  sui)|)uratiiig  subpei'iloiieal 
myoma.  The  ])atieiit  was  in  a  des|)ei-ate  condition  when  she  left  the  table,  and 
died  on  the  third  day.  In  such  a  case  the  surgeon  has  no  alternative  but  to 
operate.  This  case  is  reported  in  detail  in  the  chapter  mi  Su|i])Ui-ating  Myomata 
(see  J).  1 ")()). 

43 


674 


MYOMATA    OF    THE    UTERUS . 


DEATHS  Dl'E  TO  PERITOXmS  FOLLOWING  AN  ABDOMINAL 
HYSTEROMYOMECTOMY. 


Gyn.  No. 

Autopsy  Su. 

Day     after 

Cultures. 

Source  of  Infections  and  Compli- 

'm 

Operation. 

cations. 

69 

5th 

Staphylococcus 

^'ol^'ulus  of  ileum. 

aureus. 

701 

4th 

729 

i98 

5th 

General    B.    coli. 

Diphtheritic  enteritis,  sHglit  peri- 
tonitis. 

963 

237 

3d 

Cultures        from 
abd.  cavity  neg- 
ative. 

1767 

385 

8th 

Staphylococcus 
aureus. 

Separation  of  abdominal  wound, 
and  omentum  seen.  Cough  con- 
tinuous before  and  after  opera- 
tion. 

2713 

(itli 

3008 

561 

4tli 

Cultures  nega- 
tive. 

Dense  pelvic  adhesions. 

3198 

595 

2(1 

Streptococcus. 

Abdomen  reopened. 

3493 

666 

17tli 

Staph,  aureus. 

3882 

14tli 

Slow  general  infection. 

3898 

6tli 

Den.se  adhesions,  tear  in  external 
coat  of  ileum,  with  .subsetiuent 
perforation. 

4609 

6th 

Sloughing  submucous  myoma. 

5302 

954 

lOtli 

B.  coH. 

Dense  adliesions  with  perforation 
of  sigmoid. 

5858 

2,1 

Streptococcus. 

Carcinoma  of  body  of  uterus.  (See 
Cullen's  "Cancer  of  the  Litems, " 
p.  454,  Fig.  237.) 

7158 

3d 

Suppurating  myoma. 

7863 

8th 

Slow  general  infection. 

8732 

1734 

7th 

Streptococcus. 

Sarcomatous  degeneration  of  my- 
oma. 

10669 

2162 

4th 

General  peritonitis.  Rent  in  rec- 
tum. 

10749^ 

4th 

12209 

7th 

Dense  intestinal  and  pelvic  adhe- 
sions and  rupture  of  an  ovarian 
abscess. 

12587 

2651 

5th 

C.    H.    I.    K. 

10th 

Advanced  carcinoma  of  bodv  (Fig. 

180,  p.  286). 

Ca.scs  oS5s  and  ('.  H.  I.  K.  isvv  p.  2S())  afford  ty])ical  cxaniplcs  of  peritonitis 
d('\-('!o})in(z;  when  a  supravaginal  hysterectomy  has  been  i)erfornuMl  in  cases  of 
supposedly  simj^le  inyoina,  hut  where  carcinoma  of  the  body  was  also  present. 
The  foul  discharge  is  very  prone  to  infect  the  field  of  operation,  and  peritonitis 
speedily  follows.  Death  in  Case  5858  occurred  on  \hv  second  day  and  was  due 
to  a  streptococcic  infection.  This  case  is  reported  in  detail  in  ("ullen's  "(  ancer 
of  the  Uterus,"  j).  454  (Fig.  237).  In  Case  8732  jx'ritonitis  resulted  from  acci- 
dental soiling  of  the  peritoncnim  with  sarcomatous  tissue.  After  we  had  tied 
the  left  ovarian  vessels  and  round  ligament  and  liad  begun  to  work  down  to 
the  left  uterine  vessels  a  slight  tear  in  the  large  tumor  allowed  a  brain-like 
material  to  ooze  out  near  the  uterine  vessels.  Sarcoma  was  at  once  diagnosed, 
and  complete,  instead  of  supravaginal,  hysterectomy  performed.     The  patient, 


RESULTS    OF    OPKKATIOXS    FOR    UTKRIXF    MYOMATA.  675 

howevLT,  died  of  (general  pcritijiiitis  on  the  sc\ciith  day.  Large  sarconialous 
areas  are  especially  imnw  to  undergo  coagulation  necrosis  and  become  infected. 
The  case  is  reported  in  detail  on  p.  215. 

In  Case  12209  the  death  was  certainly  due  to  infection  from  a  large  ovarian 
abscess.  The  pulse  before  operation  was  between  150  and  160.  Filling  the  en- 
tire right  lower  alxloinen  was  a  tumor.  .\l)ove  this  the  intestines  and  omentum 
were  everywhere  adherent.  On  gradually  hxjsening  uj)  the  mass  we  found  it  to 
be  composed  of  a  myomatous  uterus  with  a  densely  adherent  ovarian  al^scess 
on  the  right.  The  abscess  was  firmly  adherent  to  the  intestinal  loops.  Its  walls 
ruptured,  and  about  ten  ounces  of  greenish-yellow  pus  were  evacuated,  with  little 
soiling.  Abdominal  hysterectomy  was  performed.  The  ])atient"s  condition 
was  desperate,  and  that  night  her  temperature  reached  105°  F.  On  the  fifth 
day  she  developed  phlebitis  in  the  left  leg.  She  died  on  the  scA'cnth  day.  In  such 
a  case  little  else  could  have  been  done.  Where  there  are  signs  of  an  abscess  low 
down  in  the  pelvis,  however,  the  better  plan  is  to  attempt  evacuation  through 
the  vagina,  and  it  is  astonishing  to  see  how  the  densely  adherent  pelvic  structures 
loosen  up  and  the  tumors  that  at  the  first  operation  were  so  firmly  fixed  that  tlieir 
enucleation  would  have  been  impossible  can  now  be  removed  with  relatively 
little  difficulty.  The  disappearance  of  the  induration  is  often  as  striking  as  that 
noted  when  evacuation  of  an  appendix  abscess  is  followed  months  latei'  by  the 
easy  removal  of  the  appendix.  In  the  case  just  cited,  however,  the  abscess  was 
too  high  up  to  l)e  readily  attacked  from  below,  and  immediate  ()p(>ration  was 
imperative. 

In  Cases  3898  and  5302  the  peritonitis  was,  in  a  large  measure  at  least,  due 
to  injury  of  the  bowel  at  operation.  In  Case  3898  the  omentum,  rectum,  and 
loops  of  small  bowel  were  densely  adherent  to  the  enlarged  uterus.  During  the 
liberation  of  adhesions  the  outer  coat  of  the  small  bowel  was  injured  at  one  point. 
This  tear  was  closed  with  three  sutures.  The  temperature  and  ])ulsc  rose  gradu- 
ally after  operation,  and  on  the  second  day  the  patient  c()ni])lained  of  excruci- 
ating pain  on  the  right  side,  over  the  site  of  the  intestinal  sutiu'e.  This  j)ain 
became  so  intense  that  the  abdomen  was  opened,  and  |)ei-foi'ation  of  the  bowel 
found  at  the  point  of  sutui'e.  Death  soon  followed.  It  looks  \-ci-y  much  as  if 
the  injury  at  the  time  of  ojx'ration  had  involved  nol  merely  the  outer,  but  also 
the  middle  and  inn(>r,  intestinal  coats.  We  ha\'e  nole(l  that  where  dense  intesti- 
nal adhesions  exist ,  the  lumen  of  the  bowel  may  be  di'awn  out  as  a  liliform  lube 
for  a  considerable  distance  into  the  abdomen.  Such  adhesions  should  be  as 
carefully  turned  in  as  an  appendix  stum|),  otherwise  thei'e  in.ay  be  danger  of 
general  peritoneal  infection. 

In  Case  10749^  a  coloi-ed  woman,  aged  forty-three,  had  mai-ked  pain  in  the 
lower  abdomen.  The  myomatous  utei-us  reached  to  the  costal  margin  on  the 
right  side.  The  pelvic  j)ortion  of  the  tumor  was  embedded  in  adhesions.  \v- 
cordingly,  the  hysterectomy  was  very  dilliiailt.  Two  vaginal  and  two  abdominal 
drains  wei'e  emj)loyed.     ( )n  the  ex'ening  of  the  third  day  an  enema  consisting  ol 


676  MYOMATA    OF    THE    UTERUS. 

500  c.c.  of  soapsuds  was  given.  This  was  expelled  clear.  Just  at  this  time 
the  jjaticnt  conijjlained  of  acute  j)ain  in  the  lower  abdomen,  Hanks,  and  also 
beneath  the  ng\\\  costal  mar<j;in.  The  pulse  rose  to  140,  but  the  temjx'rature 
remained  at  99.")°.  The  ])atient  vomited  much  clear  fluid  and  was  in  a  profuse 
perspii'ation.  Two  liours  later  she  was  lyinij;  with  the  legs  drawn  up:  the  res- 
pirations were  rapid.  She  became  delirious,  the  pulse  gradually  grew  weaker, 
and  she  died  early  on  the  following  morning.  The  autopsy  showed  a  general 
fibrinous  p(>ritonitis,  and  at  the  junction  of  the  sigmoid  with  the  lower  portion 
of  the  rectiun  an  opening  in  the  bowel  o  cm.  long.  Through  this  the  enema  had 
been  injected  into  the  abdominal  cavity. 

At  times  the  ])elvis  presents  such  a  ragged  appearance  as  a  result  of  the 
dense  adhesions  that  a  hole  in  the  bowel  may  be  readily  overlooked.  In  every 
case  in  which  thei-e  had  been  the  slightest  possibility  of  injury  the  most  careful 
inspection  should  l)e  made. 

In  Case  5302  the  lower  two-thirds  of  the  abdomen  was  filled  with  a  myomatous 
growth.  At  operation  dense  adhesions  were  encountered.  There  was  an  ap- 
pendix abscess,  a  right  pyosalpinx,  and  an  al)scess  of  the  right  ovary.  The 
tumor  was  firmly  fixcnl  to  the  ])elvic  floor,  rectum,  colon,  sigmoid  flexure,  and 
anterior  abdominal  wall.  The  urine  before  operation  contained  a  moderate 
amount  of  albumin  and  some  hyaline  casts.  After  operation  it  showed  many 
casts.  The  patient  died  on  the  tenth  day.  At  autopsy  perforation  of  the  sig- 
moid flexui-e  was  found.  This  had  first  giv(>n  rise  to  a  localized  peritonitis,  and 
latei'  the  geiiei-al  peritoneal  cavity  had  become  involved. 

The  ))atients  who  succumbed  to  peritonitis  usually  die(l  within  the  first 
six  days,  but  in  some  cases  the  infection  was  a  slower  one:  in  Case  3882,  for  in- 
stance, the  i)atieiit  li\-ed  until  the  fourteenth  day,  and  in  Case  3493,  until  the 
seventeenth  day.  Where  the  infection  is  stre])tococcic,  as  in  Case  5858,  the 
termination  may  be  appallingly  i-apid,  this  patient  dying  on  the  second  day. 

We  regret  that  our  bacteriologic  examinations  are  not  complete.  In  those 
cases  in  which  the  second  ojx'ration  was  undertaken  the  patient  was  usually 
in  such  a  desperate  condition  that  all  eflorts  wei-e  directed  to  doing  what  was 
necessary  and  getting  the  patient  off  the  table  at  the  earliest  possible  moment. 

In  the  i-apid  streptococcic  peritonitis  cases  o{)eration  avails  little  unless  per- 
loi'ined  within  the  first  few  houi's,  before  the  infection  has  become  general.  Care- 
lul  wiping  off  of  the  ])elvic  walls  and  the  intestinal  loops  in  the  vicinity,  with 
wide-sj)read  drainage  of  the  pelvis  with  gauze,  occasionally  yields  good  results. 
In  the  slow  peritoneal  infections  wide-spread  drainage  is  jwactically  all  that  can 
be  accomplished.  Where  it  is  necessary  to  I'eopen  the  abdomen,  we  have  found 
it  wiser  to  make  a  new  incision  instead  of  opening  up  the  old  abdominal  wound. 

From  the  foi'egoing  it  will  Ix-  seen  ihal  in  many  of  the  cases  peritonitis  un- 
doubtedly (le\'elo))e(I  fiom  an  ahcady  existing  pelx'ic  infection,  and  in  neai'ly 
every  case  the  hvsterectomv  was  a  verv  diflicult  one. 


RESULTS  OF  OPERATIONS  FOR  UTFRIXK  MV(J.MATA.  677 

Deaths  from  Intestinal  Obstruction  Following  Abdominal  Hysteromyomectomy. 
— In  Case  6217  great  diffieulty  was  experienced  in  covering  in  the  raw  areas  on 
account  of  the  marked  distention  of  the  intestines.  Finally,  it  was  necessary 
partly  to  eviscerate  the  patient  before  the  parts  could  be  properly  approximated. 
This  maneuver  was  probably  responsible  for  the  subsequent  obstruction,  as  in 
replacing  the  intestine  some  kinking  might  have  taken  place,  and,  as  was  pointed 
out  at  a  recent  meeting  of  the  American  Medical  Association,  nmch  handling 
of  the  bowel  is  often  followed  by  prolonged  atony.  There  are  certain  patients 
that  have  marked  distention  of  the  intestine  notwithstanding  the  most  careful 
preliminary  preparations. 

In  Case  10486  the  patient  k'ft  the  operating  tal)le  in  good  condition,  l)ut  on  the 
third  day  the  temperature  rose  to  101.6°  F,  and  the  pulse  to  104.  On  the  fourth 
day  an  enterostomy  was  done.  The  intestines  were  enormously  distended,  owing 
to  the  presence  of  a  stricture  in  the  small  bowel,  10  cm.  from  the  ileocecal  valve, 
a  loop  of  bowel  having  become  adherent  to  a  raw  area  near  the  pelvic  brim. 
This  case  again  emphasizes  the  great  importance  of  covering  over  any  raw  areas 
with  peritoneum,  thus  leaving  no  point  at  which  intestines  may  adhere. 

In  Case  12216  we  were  dealing  with  a  large  myomatous  uterus.  A  sul)perito- 
neal  nodule  had  suppurated  (Fig.  104,  p.  136)  and  become  adherent  to  the  anterior 
abdominal  wall.  Our  attempts  to  draw  the  peritoneum  over  the  raw  area  left 
on  the  anterior  abdominal  wall  were  not  very  successful  on  account  of  the  indurated 
condition  of  the  surrounding  tissue.  Partial  obstruction  developed  on  the  sixth 
day.  On  the  eighth  day  the  gut  was  found  adherent  to  the  anterior  abdominal 
wall,  and  kinked  at  this  point.  Death  followed  the  .same  day.  In  this  case 
we  are  certainly  open  to  criticism,  as,  knowing  the  dangers  at  operation,  we 
should  have  opened  the  abdomen  as  soon  as  the  obstruction  commenced.  Our 
reason  for  delay,  however,  arose  from  the  fact  that  the  bowels  had  been  thoroughly 
moved  a  few  days  after  operation. 

DEATHS    DUE    TO    INTESTINAL    OH.STRITCTION     FOLLOWIXC     A.X     AliDO.MIXAI, 

HYSTEROMYOMECTOMY. 

„         ,,  .XT  I^AV  .\kter         Secondary  Oper-  ^, 

(jyn.  No.  Aut.  No.  Operation.  ation.  Co.mplications. 


None.  Great  dilliculty  in  i^cttiiig  a  proixT 

(■\j)osur('  on  account  of  ilisttMuled 
intcsl  incs. 

Mxploralory.  I'arlial  olislruclion  lictorc  liystcr- 

cctoniy. 

lioleaso     of    ob-      Ileum  adluTcnt    to  I'di:*-  of  pelvis 
struetion.  after  operation. 

lOxploratoiy.             Siipiiuratinji   myoma    adherent    to 
anterior  abdominal   wall.      I'o.st- 
operative  intestinal  adhesions  at 
that   point. 
S.  1566  8th.  None.  


678 


MVOMATA    OF    THK    ITERUS. 


Deaths  from  Shock  Following  Abdominal  Hysteromyomectomy. — The  cause 
of  death  in  Case  1703  is  not  clear.  After  removal  of  the  uterus,  which  extended 
up  to  the  ribs,  a  Mikulicz  drain  was  introduced  and  the  abdomen  closed.  The 
patient  never  rallied  .'Satisfactorily  after  the  operation,  notwithstanding  the  fact 
that  little  blood  was  lost.  The  pulse  rapidly  rose  to  16S  and  the  resj)irations 
to  40.     She  died  fourteen  hours  after  operation. 

Case  4607  was  one  of  carcinoma  of  the  cervix  associated  with  a  sul)mucous 
myoma.  When  the  necessary  extensive  hysterectomy  had  l)een  completed,  the 
pulse  was  hardly  perceptible.  In  this  case  the  tuberculosis  of  the  hip  prevented 
the  necessary  flexion  of  the  thigh,  and  rendered  the  proper  exposure  of  the  pelvic 
structures  difficult.  Much  blood  was  lost.  Th(^  yxitient  never  recovered  from  the 
effects  of  the  operation  and  died  twc]\'e  liours  after  Icax'ing  the  table. 

In  Case  5010  the  patient  entered  tlie  liospital  in  a  precarious  condition. 
Operation  was  delayetl  in  the  hope  that  there  might  be  some  improvement,  but 
she  steadily  lost  in  strength.  The  abdomen  having  been  opened  and  the  omentum 
drawn  gently  back,  free  pus  welled  up  out  of  the  pelvis.  The  condition  present 
was  exactly  as  if  one  had  poured  half  a  liter  or  more  of  pus  into  a  pelvis  partially 
filled  with  a  multinodular  and  firmly  adherent  myomatous  uterus.  It  was 
impossible  projx'rly  to  drain  the  various  pockets.  Hysterectomy  was  attempted, 
but  the  tissues  were  everywhere  almost  like  cartilage.  The  pulse,  which  was  120 
and  weak,  rapidly  increased  as  the  operation  progressed,  and  the  patient  died 
just  as  the  abdomen  was  being  closed.  Had  we  known  of  the  l)isection  method 
at  this  time  the  operation  could  have  been  performed  iinich  more  speedily, 
and  it  is  possible  that  the  patient  might  have  been  .saved. 


DE.\THS  DUE  TO  SHOCK  FOLLOWING  ABDOMINAI>  HYSTEROMYOMECTOMY. 


Gyn.  No. 

Autopsy  No. 

Time  after  Opi 

TION. 

1703 

14  liours. 

4607 

12  hours. 

.")()1() 

908 

On  taliie. 

.')617 

On  table. 

6017 

Secondary 

6760  1^ 

13.S7 

On  table. 

rose/ 


9030 


Complications. 


Carfinonia  of  cervix:  tulxTcu- 
losis  of  iiip. 

Abscess  in  niyonui:  chronic  ad- 
hesive pericarditis;  fatty  de- 
generation of  liver. 

Bronchitis,   "weak  heart." 

Sii)U,a;hin,ii;  submucous  myoma. 

Aixlominal  myomectomy  two 
months  before:  later  profu.se 
lieniorrhajxe:  intestinal  adhe- 
sions to  titeriiie  wound. 

Rupture  of  large  infected  ovarian 
cyst  into  abdominal  cavity. 


In  Case  5617  there  was  weakness  and  .shortness  of  breath.  The  pulse  was  130 
and  feeble.  On  account  of  bronchitis,  chloroform  was  first  used,  but  the  respir- 
ations ceased.     After  resuscitation  ether  was  administered.    The  pulse  rose  to  168, 


KKSILTS    OF    OI'KHATIOXS    FOR    I'TERIXE    MVo.MATA.  679 

boconiing  weaker  and  iri'e;u:;ular,  and  the  ])atient  died  on  the  tal)U'.  The  hirge 
myomatous  tun  Kir  had  supjiurated  and  hi'oken  througli  into  the  uterine  cavity. 
The  wisdom  of  ojxTating  on  such  a  case  may  be  ([uestioned,  but  it  is  perfectly 
clear  that  without  operation  death  was  certain,  and  in  other  apparently  more 
desperate  cases  patients  have  survived  the  operation  and  have  been  restored 
to  perfect  health. 

In  Case  6017  there  were  great  weakness,  shortness  of  breath,  and  swelling  of 
both  legs.  The  vagina  was  filled  with  a  large,  rounded  mass,  slightly  gangrenous 
in  several  places.  This  tumor  was  continuous  with  t he  myomatous  uterus,  which 
extended  to  the  umbilicus.  At  operation  vaginal  myomectomy  was  done  and  the 
uterus  removed  from  above.  The  hystertrtomy  was  very  difficult,  the  growth 
being  to  a  great  extent  behind  the  bladder.  The  entire  operation  occupicnl  three 
hours.  After  infusion  the  jxitient  steadily  ini|»i-o\-ed  until  4  a.m.  on  the  next 
morning,  when  she  .suddenly  felt  faint.  The  pulse  and  respirations  became  very 
rapid,  and  she  presented  the  typical  symptoms  of  hemorrhage.  The  abdomen 
was  opened,  but  there  was  no  sign  of  bleeding.  She  died  just  as  the  abdomen 
was  closed. 

We  are  certainly  open  to  criticism  in  this  case.  When  a  sloughing  submucous 
myoma  is  present,  this  should  be  completely,  or  as  far  as  po.s.sible,  removed. 
Under  no  circumstances  should  the  hysterectomy  be  undertaken  until  the  dangers 
of  infection  from  the  necrotic  submucous  growth  are  past. 

The  operation  in  Case  7036  was  secondary  to  a  myomectomy  done  two  months 
before.  The  patient  was  so  weak  as  a  result  of  the  intestinal  obstruction  that  she 
died  on  the  table.     For  the  full  details  of  this  case  see  j).  ofiti. 

In  Case  9030  the  ])atient  was  .so  weak  and  anemic  on  admission  that  ojM-ration 
was  deferred.  Later  a  large  myomatous  uterus  was  exposed,  and  filling  the  right 
lumbar  region  and  extending  to  the  right  side  of  the  uterine  mass  as  far  as  the 
costal  margin  was  a  large  cystic  accunmlation  with  walls  varying  in  thickness. 
This  was  everywhere  adherent  to  the  intestines.  During  its  liberation  the  cyst 
ruptured,  and  a  large  amoimt  of  foul-snieliing  puruleiil  material  was  scattere(l 
throughout  the  abdominal  cax'ity.  This  was  immedialely  Hushed  out  wit  h  a  large 
amount  of  salt  solution,  and  the  uterus  (juickly  I'emovi'd.  Immediately  after  the 
operation  the  patient  was  in  a  state  of  colla])se.  She  soon  rallied,  and  a  few  hours 
later  the  pulse  was  easily  counted.  Toward  excning  there  wei-e  signs  of  collapse. 
The  pulse  could  not  be  counted.  The  patient  was  gasping  foi-  aii"  and  was  xcry 
cyanotic.     She  died  eight  hours  after  o|)erati()n. 

In  this  case  also  ojiei'ation  offered  the  only  hope.  With  oiu'  pi'eseiit  know  ledge 
of  the  ojx'i'ative  technie  we  would  wipe  out  the  pus  that  had  escaped,  and  under 
no  circumstance  I'un  the  I'isk  of  spreading  it   by  llu>hing  tln'  abdominal  ca\'ity. 

I'rom  1  he  al)o\('  it  is  seen  t  hat  in  six  of  I  he  siacii  deat  lis  from  shock  following 
abdouiiiial  hystei'omyoiuectomy  the  fatal  leruiinatioii  was  not  unlooke(|  foi".  all 
being  despei-ale  cases.      In  ( 'ase  17().")  we  are  at  a  loss  to  account  for  the  death. 


680 


MYOMATA    OF   THF.    UTERUS. 


Fatal  Pulmonary  Embolism,  Following  Abdominal  Hysteromyomectomy. — - 
In  four  of  the  901  abdominal  hystcroinyoniectoniies  tho  patients  died  of  pul- 
monary embolism. 

In  Case  7361  thei'c  was  a  simple,  uncomplicated,  su{)ra vaginal  hysteromyo- 
mectomy. The  appendages,  which  were  normal,  were  left  in  sitx.  The  patient 
did  well  until  the  fourteenth  day,  when,  while  talking  to  another  patient,  she  com- 
plained of  feeling  ill,  grew  pale,  and  suffered  from  dyspnea  and  suffocation.  The 
face  was  covered  with  beads  of  perspiration.  She  responded  to  questions  and 
comj)lained  of  a  "weight"  on  the  chest.  The  pulse  was  slow  and  full,  but 
irregular.  About  an  hour  later  dilatation  of  the  left  pujiil  was  noted,  and  the 
patient  responded  to  questions  by  nodding  the  head.  There  seemed  to  be  paraly- 
sis of  the  left  arm  and  the  right  side  of  the  face.  The  breathing  was  now  very 
stridulous.  The  condition  imj)roved  somewhat  during  the  day,  but  toward 
evening  the  pulse  l)ecame  irregular  and  dropped  a  beat  freciuently.  .Shortly 
after  midnight,  just  fifteen  hours  after  the  onset,  the  patient  gave  a  gasp  and 
died.  Autopsy  showed  embolism  and  thromboses  in  the  pulmonary  arteries, 
and  old  tuberculous  lesions  in  both  lungs. 

DEATHS  FROM  PULMONARY  EMBOLISM  FOLLOWING  AN  ABDOMINAL 
HYSTEROMYOMECTOMY.* 


GvN.  No. 

Autopsy  No. 

Character  of 
Operation. 

Postoperative 
conditio.v. 

Day  of  Death 

7361 
9675 

S.   1682 
S.  1872 

1445 
1936 

Simple. 
Simple. 

Simple. 
Simple. 

Good. 

Thrombosis    of 

ovarian  vein. 

Good. 

Good. 

left 

Fifteenth. 
Fifth. 

Twelfth. 
Fourth. 

In  Case  9675  the  patient  was  a  stout,  rather  weak  woman.  She  had  a  chronic 
ncjihritis.  The  uterus  was  free  from  adhesions,  and  could  have  been  easily 
removed  had  it  not  been  for  the  difficulty  in  obtaining  the  necessary  exposure. 
The  ])atient  did  fairly  well  for  two  days,  but  grew  weak  on  the  fffth  day,  and 
died  apparently  as  th(^  I'esult  of  ])rofound  asthenia.  At  autopsy  thrombosis  of  the 
left  ovarian  vein  was  found.  The  left  pulmonary  artery  was  normal,  but  on  open- 
ing the  right  a  large  thrombosed  mass  was  found  lying  in  the  branch  to  the  lower 
lobe.  This  thrombus  did  not  conqjlctely  fill  the  vessel.  It  was  rough,  of  agrayish 
color,  and  had  other  clots  attached  to  it.  Its  central  jiortion  was  aj)))arently 
undergoing  softening. 

In  San.  No.  1()S2  the  uterus  was  easily  removed,  and  the  a{)pendages  were 
normal.  The  patient  dieil  suddenly,  apparently  of  jHilmonary  embolism,  on  the 
twelfth  day. 

*  In  Case  12587  death  was  due  primarily  to  a  general  peritonitis.  At  autopsy,  in  addition 
to  thrombosis  of  the  uterine  and  vesical  veins,  pulmonary  embolism  was  noted.  The  lungs  were 
also  the  seat  of  abscesses,  bronchopneumonia,  acute  bronchiectasis  and  broncliitis,  and  there 
was  an  acute  fibrinous  pleuritis. 


RESULTS    OF    OPERATIONS    FOR    UTERINE    MYOMATA. 


681 


In  San.  No.  1872  the  patient  was  a  very  IVail  woman,  fifty-one  years  old,  with  a 
hemoglobin  of  50  ])er  cent.  The  myomatous  uterus  was  removed  without  diffi- 
culty. On  the  fourth  day  she  was  as  bright  as  usual,  when  suddenly  she  screamed, 
became  unconscious,  and  died  within  a  few  minutes.  Embolism  was  probably 
the  cause  of  death. 

In  not  one  of  the  four  cases  in  which  the  patient  died  of  pulmonary  embolism 
had  we  any  evidence  of  the  embolus  Ix'ing  due  to  pelvic  infection.  In  each  case 
the  operation  was  a  simple  uncomplicated  one  and  the  convalescence  was  normal 
until  the  symptoms  of  embolism  developed. 

Other  Causes  of  Death  Following  an  Abdominal  Hysteromyomectomy. 
In  addition  to  the  deaths  following  abdominal  hysteromyomectomy  and  due 
to  general  peritonitis,  intestinal  obstruction,  shock,  and  puhnonary  embolism, 
there  were  12  other  cases.     The  cause  of  the  death  in  these  cases  is  shown  in 
the  following;  table: 


OTHER  CAUSES  OF  DEATH  FOLLOWING  AN  ABDOMINAL  HYSTEROMYOMECTOMY. 
Gyn.  No.  AnTOPSY  No.  Cause  of  Death. 


10095 
13016 


Fatal  hemorrhage  from  a  uterine  artery  on  the  eighth  day 
due  to  too  early  absorption  of  the  catgut  Hgature. 

Lobar  pneumonia  on  seventeenth  day. 

Abscess  of  lung  and  bronchopneumonia.  Death  on  twen- 
tieth day. 

Convalescence  interrupted  by  double  basal  pneumonia. 
Symptoms  suggestive  of  gastric  carcinoma.  Death  from 
acute  dysentery  in  eleventh  week. 

Did  well  till  twenty-first  day,  then  developed  severe  diar- 
rhea and  died  on  twenty-eighth  day. 

Persistent  nausea.  Abdomen  opened  on  fourteenth  ilay. 
No  signs  of  obstruction  or  peritonitis.  Deatii  the  same 
evening. 

Persistent  nausea;  abdomen  reopened,  no  signs  of  obstruc- 
tion or  peritonitis.      Death  on  third  day. 

Chronic  diffuse  neplu'itis.  Death  on  hfth  day.  Abtlomen 
reopened;   no  peritonitis  or  obstruction. 

Acute  suppression  of  urine,  due  to  a  chronic  ditTuse  neph- 
ritis. Death  on  the  .second  day.  Operation:  comiilete 
removal  of  uterus  by  tlic  Wertlieim  method  for  carcinoma 
of  the  cervix.  The  diffuse  adenomyoma  of  the  l)ody  was 
discovered  only  in  the  laboratorj'.  (Kei)orie(l  in  full  in 
■' Atlenomyoma  of  the  Uterus,"  p.  211.) 

Found  dead  in  i)ed  on  t wciity-fiftli  day.  Had  had  |in'vi- 
ous  attacks  of  syncope. 

Probable  myocai-ditis;    dcatli  on  fourlli  day.      No  autops}-. 

Myocarditis;  death  on  twclftli  day. 


Fatal  Secondary  Hemorrhage.  In  Case  .S977,  as  a  result  of  too  early  ;ibsorp- 
tion  of  the  catgut  ligature  conti'oHing  the  left  uterine  ;irtery,  the  patient  died  of 
sudden  and  fatal  hemorrhage  from  this  vessel  on  the  eighth  day. 

In  this  case  the  ])el\'is  was  lilieil  with  ;i  large  globular  mass  about  the  size 
of  a  fetal   head  and   the  cervix   was  drawn   ui)  hiuii.     The  mvomatous  uterus 


682  MYOMATA    OF   THK    UTERUS. 

reached  the  uinhihcus.  The  operation  proved  to  be  rehitively  simple.  On  the 
eighth  day  the  j)atient  eallcd  a  nurse,  saying  that  she  felt  faint.  Her  pulse 
rapidly  became  impercej)tibl(',  she  was  gasping  for  breath,  her  face  was  cyan- 
otic, the  extremities  were  cold;  death  resulted  in  a  few  minutes.  At  auto])sy 
a  considerable  amount  of  fluid,  especially  clotted  blood,  was  found  in  the  ab- 
dominal cavity.  The  hemorrhage  appeared  to  have  come  from  the  left  uterine 
artery,  proliably  as  i'(^sult  of  too  early  an  absorption  of  the  catgut  ligatures. 
TluM'e  was  slight  atheroma  of  the  coronary  arteries  and  faint  evidences  of  a 
myocarditis.      Death  was  undoubtedly  due  to  the  hemorrhage. 

Pulmonary  Abscess. — Tn  Case  lllSO  a  large  nuiltinodular  myomatous  uterus 
was  removed.  On  the  fourth  day  an  area  of  dulness  could  be  detected  in  the 
right  lung.  It  was  demonstrable  both  in  front  and  behind.  The  temperature 
varied  from  102°  to  104.5°  F.  for  a  week,  and  when  the  patient  was  transferred 
to  the  nuHlical  ward  on  the  sixteenth  day,  it  was  about  100.5°  F.  The  pulse 
was  rapid  and  the  general  condition  unfavoral)le.  She  died  eighteen  days 
after  operation.  Auto))sy  revealed  a  bronchopneumonia  of  the  left  lung,  with 
a  large  encapsulated  gangrenous  abscess  in  the  lower  lobe.  There  is  no  evidence 
that  the  operation  was  in  any  way  responsible  for  the  pneumonia  or  for  the  pul- 
monary abscess. 

In  Case  12587  the  ])atient  was  a  negress,  thirty-nine  years  of  age.  After 
removal  of  a  large  myomatous  uterus  she  developed  a  l)ronchopneumonia  and 
died  on  the  fourth  day.  At  auto])sy  acute  fibrinous  pelvic  ])eritonitis,  thrombo- 
sis of  the  uterine  and  vesical  veins,  embolism  of  the  pulmonary  arteries,  pulmo- 
nary abscesses,  bronchoj-jueumonia,  acute  bronchiectasis  and  bronchitis,  acute 
fibrinous  pleuritis,  and  acute  <liphtheric  colitis  were  found.  The  pulmonary 
abscesses  were  probably  secondary  to  the  emboli.  This  case  is  included  among 
the  deaths  from  pei-itoiiitis  on  p.  074. 

Acute  Suppression  of  Urine. — The  death  in  case  V.  H.  T.  511,  from  acute  sup- 
pression, followed  a  Wertheim  operation  for  carcinoma  of  the  cervix  in  a  patient 
with  chronic  nephritis.  The  exact  conditions  and  dangers  were  explained  to  the 
patient  before,  and  she  chose  operation. 

The  adenomyoma  was  not  recognized  until  after  removal  of  the  uterus.  This 
case  in  a  sense  should  not  be  inchided  under  deaths  following  operations  for  myo- 
mata,  but,  as  it  foi-ms  one  of  (jur  total  number  of  myoma  cases,  it  hardly  seems 
fair  to  include  il  in  one  place  and  omit  it  in  another.  In  order,  therefore,  to 
remove  even  the  slightest  ])ossible  suggestion  of  bias  and  to  be  on  the  safe  side 
we  have  included  it.  The  same  may  be  said  of  Case  8183,  in  which  the  carci- 
noma of  the  c(>rvix  was  the  dominant  lesion  and  the  myoma  was  not  large. 

Myocarditis. — The  clinical  picture  in  Case  10095  suggested  myocarditis, 
but  the  exact  condition  could  not  be  ascertained,  as  no  autopsy  was  obtainable. 

In  Case  18016,  a  negress,  thirty  years  old,  was  well  nourished  and  healthy 
looking.  There  was  marked  pulsation  in  the  arteries  on  the  right  side  of  the 
neck.     There  was  a  faint,  blowing,  systolic  murmur  heard  most  distinctly  in  the 


RESULTS    OF    OPKKATIOXS    FOR    ITKRIXK    MVOMATA.  HS3 

second  left  intercostal  space.  It  was  traceable  to  the  vessels  of  llir  neck.  Killing 
the  lower  abdomen  was  a  niyoinatous  uterus.  This  was  removed  without 
difficulty,  and  uj)  to  within  five  minutes  of  her  death,  on  the  twelfth  day,  the 
patient  had  improved  steadily.  Two  hours  before  she  had  complained  of  pain  in 
the  right  leg.  This,  however,  was  not  severe.  The  patient  suddenly  gasped  f(jr 
breath,  became  semiconscious,  and  died  in  five  minutes.  The  coincident  j)ain 
in  the  right  leg  and  the  sudden  death  naturally  suggested  pulmonary  embolism, 
but  at  autopsy  acute  myocarditis  (degenerative),  chronic  fibrous  myocarditis, 
and  cardiac  dilatation,  together  with  lymphatic  hyperplasia,  were  found. 


Death  Following  Bisection  of  the  Uterus. 
In  68  of  the  abdominal  hysterectomy  cases,  prior  to  removal  of  the  utei'us. 
it  was  bisected.     On  account  of  the  newness  of  this  operation,  we  have  considered 
these  cases  by  themselves.     Eight  of  the  patients  died,  an  exceedingly  high 
mortality,  namely,  11.76  per  cent. 

Causes  of  Death.  Nu.mber  of  Cases. 

General  peritonitis .3 

Intestinal  obstruction 1 

Shock 2 

Pulmonary  embolism 1 

Bronchopneumonia  (wide-spread  metastases  from  sarcomatous  degeneration  of  a 

myoma) 1 

8 

Peritonitis. — The  death  in  Case  7474  was  due  to  the  fact  that  necrotic  sar- 
coma t  (jus  tissue  in  the  center  of  a  large  myoma  was  set  free  by  the  bisection. 
The  case  is  reported  in  detail  on  p.  208. 

In  Case  8598  a  negress,  twenty-nine  years  old,  had  a  hemoglol)in  of  24  per 
cent.  On  section  of  the  abdomen  dense  adhesions  were  found  between  the  tumor, 
the  pelvic  walls  and  I'eetum.  The  right  side  was  first  free<l  and  (hiring  tiie 
manipulations  an  abscess  ru])tui'e(l  and  a  considerable  aniounl  of  ci-eamy  pus 
escajx'd.  The  outer  coat  of  the  rectum  was  slightly  toriL  Hisection  was  at 
once  resorted  to  to  save  time.  The  two  halves  of  the  uterus  were  i-emoved,  and 
the  pelvis  was  i)acke(l.  The  j)atient  was  mai'kedly  shocked.  She  slowly  rallied, 
but  two  weeks  after  operation  gi'ew  weakei',  and  died  on  the  sixteenth  da\'  with 
signs  of  general  peritonitis. 

In  Case  9182  a  negi'ess,  forty-two  years  old,  hail  a  weak  ;ind  ra|)id  pulse  during 
o])eration.  ( )n  account  of  intestinal  and  genei'al  pehie  adhesions  the  utei'us 
was  bisected.  She  I'allied  slightly  aftei-  operalioii,  but  on  the  third  day  grew 
weaker  and  died  (jii  the  f(jllowing  day.  Aut .  No.  1809  revealed  a  geiiei'al  ))ui'ule!it 
peritonitis. 

Intestinal  Obstruction.  In  Case  9.5.36  the  opei-ator  found  the  tunioi'  filling 
the    |)eh'is   and    (irmly    fixed    by   dens(>   adhesions.      Bisection    olTeicd    the   best 


684  MYOMATA    OF    THE    UTKItUS. 

prospect.s.  Posteriorly,  the  tumor  was  so  densely  adherent  to  the  reetiini  that 
a  portion  of  it  had  to  be  left  attached  to  the  bowel.  The  pelvis  was  packed  with 
gauze,  and  the  patient  left  the  table  in  good  condition.  During  the  n(>xt  day 
she  had  severe  pain  in  the  left  side  of  the  pelvis;  the  pulse  was  110,  the  temper- 
ature 101.5°  F.  Vomiting  and  distention  developed,  and  the  patient  died  on  the 
fourth  day  with  definite  signs  of  obstruction.  This  case  is  reported  in  detail 
on  p.  ISO.  Here  it  will  be  seen  that  the  entire  central  portion  of  a  large  sub- 
pei'itoneal  myoma  had  undergone  sarcomatous  transformation,  and  that  the 
center  of  the  malignant  growth  had  l)ecome  necrotic.  Local  infection  naturally 
followed,  with  kinking  of  the  bowel. 

Death  from  Shock  Following  Bisection. — In  Case  8836  the  patient  was  a 
white  woman,  forty-eight  years  of  age.  Filling  the  pelvis,  and  extending  half- 
way to  the  um[)ilicus,  was  a  myomatous  uterus.  On  account  of  numerous  dense 
adhesions  bisection  was  carried  out.  In  order  to  free  adhesions  as  rapidly  as 
possible  the  bladder  and  I'ectum  were  both  opened,  l)ut  later  accurately  closed. 
The  patient,  on  leaving  the  table,  was  in  a  desperate  condition;  the  pulse  was 
loO,  very  weak,  and  irregular;  the  extremities  were  very  cold.  In  spite  of  stimu- 
lation she  died  within  a  few  hours.  In  this  case  the  subsequent  steps  of  the 
operation  clearly  demonstrate  that  we  had  shown  very  poor  judgment  in  opening 
the  l)ladder  and  rectum,  as  the  time  saved  by  opening  them  was  more  than  lost 
during  the  subsequent  closui'e. 

In  Case  8872  the  patient  was  a  white  woman,  fifty-two  years  of  age,  and  well 
nourished.  After  a  long  median  incision  through  very  thick  walls  had  been 
made,  a  large  multinodular  uterus  was  exposed.  This  tumor  was  not  adherent, 
but  had  developed  mainly  in  the  cervical  region.  Enucleation  was  carried  out 
by  first  clamping  the  ovarian  vessels  on  both  sides  and  then  bisecting.  The 
hemorrhage  was  very  profuse.  After  splitting  down  to  the  cervix,  the  operator 
pulled  the  tumor  from  its  capsule,  but  the  Ijleetling  still  persisted.  Both  halves 
of  the  uterus  were  then  removed.  The  patient  was  almost  pulseless  on  leaving 
the  table.  Toward  midnight  she  became  delirious,  and  died  at  6  a.  m.  Ex- 
tensive development  of  a  tumor  usually  renders  the  hysterectomy  difficult, 
but  with  slow  and  patient  traction  we  would  probably  have  been  able  to 
remove  the  uterus  intact  and  to  save  our  patient.  Death  was  clearly  due  to  the 
great  amount  of  blood  lost  during  the  operation. 

Death  from  Pulmonary  Embolism  Following  Bisection. — In  Case  S71o  the 
patient  was  a  negress,  forty  years  of  age.  On  section  of  the  abdomen  the  pelvis 
was  found  fille(l  with  a  multinodular  myomatous  uterus.  Bisection  was  easily 
done,  and  the  riglit  structures  were  removed  without  difficulty.  The  left  ap- 
pendages were  very  adherent.  The  gall-bladder  was  openc^l,  and  several  stones 
removed.  Convalescence  was  normal  until  the  sixth  day.  The  night  mu'se 
heard  her  cough  and  gasp,  and  by  the  time  she  reached  the  bed  the  patient  was 
dead.  Aut.  No.  1733  showed  a  perfectly  smooth  peritoneal  cavity,  but  throm- 
bosis of  the  left  common  iliac  vein.     Unfortunately,  the  pathologist  was  unaware 


RESULTS    OF    OPERATIONS    FOR    VTHHIXK    MYOMATA.  685 

of  the  apparent  eaiise  of  death,  and  the  kinj2;s  were  removed  in  the  ordhiary  way 
and  no  eniboHsni  was  detected.  Both  hnigs  showed  some  petechial  subpleural 
hemorrhages. 

The  cHnieal  ])ieture,  coupled  with  the  thrombosis  of  th(^  iliac  vein,  leaves 
little  doubt  that  the  patient  died  of  ])ulmonary  embolism. 

Bronchopneumonia  Causing  Death  after  Bisection. — In  Ca.'^e  7604  the  patient 
was  a  white  woman,  aged  forty-four.  The  enlarged  uterus  extended  above  the 
umbilicus,  and  the  bladder  was  drawn  up  as  far  as  the  umbilicus.  The  tumor 
was  adherent  to  the  rectum,  and  each  tube  was  the  seat  of  a  hydrosalpinx.  The 
uterus  was  l)iseeted.  From  the  cavity  blood-stained  serous  fluid  escaped, 
and  from  the  lower  part  of  the  uterus  a  soft  stringy  substance,  softer,  darker, 
and  more  vascular  than  ordinary  muscle  tissue.  From  an  accidental  rent  in 
the  bladder  infected  urine  escaped  into  the  pelvis.  The  patient  (i;i:i(hially  grew 
weaker  and  died  on  the  twelfth  day.  Aut.  No.  1503  revealed  gangrene  of  the  left 
ovary,  sarcomatous  metastases  in  the  lungs,  bronchopneumonia,  metastases  in  the 
chorda^  tendinea^,  on  the  tricusj)id  valves,  and  acute  endocarditis.  This  case  is 
rejxjrted  in  detail  on  p.  220. 

The  majority  of  the  cases  in  which  death  followed  bisection  were  most  diffi- 
cult, and  in  some  instances  impossible  of  accomplishment  by  any  other  method. 
A  study  of  the  cases,  however,  shows  that  wherever  there  is  inf(>ction  of  the  uterine 
cavity  or  malignant  degeneration  in  the  myomata,  the  danger  of  immediate  general 
peritonitis  is  great.  In  some  cases,  also,  great  loss  of  blood  follows  the  liisection. 
This  o])eration  should  never  be  performed  in  myoma  cases,  when  the  uterus  can 
be  removed  intact.  In  a  certain  group  of  otherwise  inoperal)le  cases  the  pro- 
cedure, however,  is  of  the  greatest  value  to  the  surgeon. 


Results  in  Vaginal  Hysteromyomectomy. 

As  seen  from  the  table,  we  had  24  vaginal  hysteromyoiiiectomies  with  no 
deaths.  In  jjractically  all  these  cases  the  uterus  was  small  and  mobile  and  was 
taken  out  readily  from  below.  In  many  of  the  ca.ses  these  myomata  were 
associated  with  prolajjsus  of  the  uterus,  and  the  operation  was  for  the  prolapse 
rather  than  for  the  myoma. 

In  nearly  all  cases  in  whleh  the  myomata  are  of  niodeiale  or  hii'ge  size  we 
prefer  o|)eniiig  the  abdomen  and  I'emoving  the  uterus  from  alio\e.  We  nre  thus 
enal)le<l  to  see  cleai'lN'  each  step  in  the  opei'ation.  and  to  cope  successfull\'  with 
the  vaiious  and  unexpected  complicating  conditions  that  are  .so  fre(|uently  met 
with. 

Final  Results  after  Operations  for  Uterine  Myomata. 
After  abdominal  myomectomy  the  results  ai'e,  on  the  \\hole,  \'ery  salist'actoi'y 
(Chapter  XXIX,  )).  ')()(')).     The  di'agging  sensations  in   the  lower  abdomen  and 
the   backache,   so  fre((uenlly   noted,   disaiijx'ar,   .and    the  palieiil   teds  ))ei'lectly 


686  MYOMATA    OF    THE    Ul  KRIS. 

well.  In  a  few  installers,  as  noted  on  p.  oGl,  a  sul)se(niciit  liystereetoiiiy  may 
be  necessary  on  account  of  the  development  of  other  myomatous  nodules. 

In  cases  in  which  a  simple  supravaginal  hysterectomy  has  been  performed 
and  the  ovaries  ha\'e  been  saved,  the  final  results  are  also  very  satisfactory, 
and  in  many  cases  the  unpleasant  phenomena  of  the  ])i-emature  menopause  have 
been  avoided.     (See  p.  603.) 

In  cases  in  which  there  has  been  much  hemorrha<ie,  the  rapidity  with  which 
the  patients  improve  after  ojx'ration  is  often  little  sliort  of  marvelous,  and  the 
hemoglobin,  whicli  piioi-  to  operation  has  been  below  80  per  cent.,  rapidly  rises 
to  60  or  70  per  cent .,  and  in  the  course  of  a  few  we(>ks  is  nearly  normal.  In  Case 
M.,  seen  in  consultation  with  Dr.  K.  W.  Meiseiiheldci',  at  York,  Pa.,  on  January 
2,  1903,  affords  an  excellent  example  of  such  improvement.  The  patient  at 
operation  was  almost  colorless,  and  during  the  o{)ei-ation  the  blood  on  the  sponge 
left  no  deeper  stain  than  if  di])ped  in  port  wine.  There  had  been  excessive 
hemorrhages,  due  to  a  very  large  submucous  myoma.  At  the  end  of  ten  weeks 
the  patient  had  improved  markedly  and  had  a  good  color.  The  improvement 
was  so  great  that  her  intimate  friends,  meeting  her  on  the  street,  did  not  recognize 
her. 

Our  death-rate,  on  the  wliole,  has  been  relatively  large,  but  it  must  be  remem- 
bered that  the  series  includes  the  cases  from  the  time  the  liosj)ital  opened  in  1SS9 
until  .July  1.  1906.  In  the  early  days  the  operative  technic  for  the  removal  of 
myomata  was  still  in  the  transition  stages  and  many  cases  that  called  for  an 
operation,  at  that  time  formidable  and  attended  with  grave  dangers,  are  now 
relatively  easy  and  can  be  pro])erly  cared  for  with  but  little  risk.  Furthermore, 
many  of  the  patients  had  passed  from  clinic  to  clinic,  the  condition  having  been 
regarded  as  inoperable,  so  that,  so  far  as  we  were  concerned,  removal  of  the 
tumor  was  attempted  as  a  last  resort.  Such  patients  would  now  be  operated 
upon  before  atlhesions,  suppuration,  or  marked  degenerative  changes  had  taken 
place.  A  glance  at  the  results  of  the  last  two  and  a  half  years  will  show  that  our 
operative  mortality  has  been  less  than  one  })er  cent. 

The  remarkal)le  improvement  that  can  often  be  obtained  by  removing  slough- 
ing submucous  myomata  fi'om  ])atients  who,  as  a  I'esult  of  the  septic  absorption, 
have  a  high  tcnipcratui'c,  a  i'a])i(l  and  weak  pulse,  and  iWi-  npparcntly  almost 
moribund,  is  simply  astonishing.      (See  ]>.  'u7.) 

Naturally,  the  removal  of  any  tumor  of  ccjiisiderable  size  and  weight  affords 
physical  relief,  which  in  some  cases  is  almost  indescribable. 

Taken  as  a  whole,  few  ojjcrations  in  surgery  give  as  nuieh  i)ermaiient  satis- 
faction as  those  for  the  removal  of  uterine  mvomata. 


KKSILTS    OF    Ol'KKATIOXS    FOK    ITKHIXK    MVoMATA.  687 

RESULTS  IN  MYOMA  CASES  AT  THE   .loHXS  Hol'KIXS  HOSPITAL  I'lloM  JILY   1 

1906,  TO  JAXl'AItY    1,   1909. 

Casks.  Dkaths.  Pkrckxtagk. 

Abdominal  myomectomy 38  0  0 

Vaginal  myomectomy 6  0  0 

Abdominal  hysteromyomectomy 192  2  1  + 

Vaginal  hystcroniyoniectoiny 2  0  0 

'lOtai  operations 238  2  .85 

Not  treated 8 

In  the  series  of  246*  euses  there  were  ;!  deaths,  two  tollowiiii;;  ahdoininal 
hysteromyomectomy,  and  on(>  in  wliich  no  opci-atioii  had  hccii  pci'toi-mcd. 
This  gives  a  mortahty  of  .85,  or  less  than  1  ])er  cent. 

In  the  194  hysteromyomectomies  all  but  two  of  the  jjatients  ((ivn.  Xos. 
14662  and  15252)  recovered — a  mortality  of  a  little  over  1  per  cent.  In  Case 
14662  the  patient  died  of  postoperative  intestinal  obstruction  on  the  twenty- 
second  day.  In  case  15252  the  w^oman  was  forty-four  years  of  age.  At  o})eration 
complicating  the  myomatous  condition  of  the  uterus  a  general  jx'ritoneal 
carcinosis  was  found.  The  origin  of  these  j)a])illary  carcinomatous  masses 
could  not  l:)e  determined. 

In  case  15477  the  patient  was  admitted  to  the  hospital  in  a  state  of  exti-enie 
asthenia  and  was  markedly  anemic.  She  died  in  a  state  of  shock  on  the  following 
day.     In  this  case,  of  course,  operation  was  out  of  the  ([uestion. 

The  reduction  of  the  operative  mortality  in  the  last  two  and  one-half  yeai's 
to  less  than  1  per  cent,  is  particularly  gratifying.  It  is  due  in  part  to  the  fact 
that  many  j)atients  came  to  the  operation  befoi'e  serious  comjiliealions  de\-elo]ied, 
but  in  a  large  measure  to  the  improved  methods  which  naturally  follow  where 
many  cases  of  the  same  kind  are  ojxM-ated  upon  in  the  .^ame  clinic. 

*  A  number  of  cases  have  been  omitted,  as  the  myomata  were  too  small  and  as  the  operation 
was  performed  for  somf  other  cause. 


NDEX  OF  CASES  ARRANGED  ACCORDING  TO  THEIR 
GYNECOLOGICAL  NUMBERS. 


This  list  does  not  include  all  the  cases  operated  upon,  but  merely  those  that  arc  more  or 
less  fully  described  in  the  text.  The  pathological  and  autopsy  numbers  are  given  in  the  accom- 
panying lists. 


Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 


No.  57 

No.  62 

No.  65 509, 

No.  69 464, 

No.  77 354,42.3, 

No.  121 

No.  143 504, 

No.  182 504, 

No.  213 504, 

No.  278 

No.  288 


No.  301 

No.  337 77, 

No.  362 461, 

No.  482 

No.  515 

No.  516  ....376,504, 

No.  562 

No.  615 

No.  659 382, 

No.  660 

No.  694 16,436, 

No.  701 11, 

No.  706 

No.  729 

No.  832 

No.  858 546, 

No.  891  ....465,504, 

No.  909 

No.  934 

No.  939 

No.  963 

No.  1033 510, 

No.  1039 

No.  1049 

No.  1069 288, 

No.  1112 

No.  1135 

No.  1150 572, 

No.  1151 

No.  1173 410, 

No.  1212 449, 

44 


533 

548 
533 
674 
426 
546 
505 
505 
505 
415 
505 
579 
448 
540 
534 
570 
505 
419 
505 
461 
555 
449 
674 
562 
674 
420 
547 
505 
586 
669 
505 
674 
562 
376 
436 
625 
508 
264 
587 
448 
540 
547 


Gyn.  No. 
Gyn.  No. 
Gyn.  No. 
Gyn.  No. 

Gyn.  No. 
Gyn.  No. 
Gyn.  No. 
Gyn.  No. 

Gyn.  No. 
Gyn.  No. 
Gyn.  No. 
Gyn.  No. 
Gyn.  No. 

Gyn.  No. 
Gyn.  No. 

Gyn.  No. 
Gyn.  No. 
Gyn.  No. 
Gyn.  No. 
Gyn.  No. 

Gyn.  No. 
Gyn.  No. 
Gyn.  No. 
Gyn.  No. 
Gyn.  No. 
Gyn.  No. 
Gyn.  No. 
Gyn.  No. 
Gyn.  No. 
Gyn.  No. 

Gyn.  No. 
Gyn.  No. 
Gyn.  No. 
CJyn.  No. 
Gyn.  No. 
Gyn.  No. 
Gyn.  No. 


1249 

1258 

1260 

13 17.. 572,  .-)79, 


PAGE 

530 
505 
568 
585, 
586 

1329 449,511 

1373 504,505 

1379 505 

1383i  ...35,451,625 

1405 504,505 

1422 507 

1441 581 

1455  ...346,527,570 

1489  ..546,568,  572, 

579, 587 

1499 386,664 

1551  ..448,579,  580, 
586 

1558 234,440 

1576 554,  570 

1579 371 

1593 586 

1610  ...71,441,  574, 
575, 579, 587 

1628 436 

1637 348,349 

1664 436 

1666 666 

1672  ...511.543,625 
1682  ...366,387,436 

1685 451,570 

1691 288 

1703 678,679 

171(5  . .  .  71 ,  574,  575, 
579, 587 

1752 541  I 

1767 673,674 

1782 288 

17S7 4  47 

1,S21 .")7() 

1852 J63,(i7() 

1862 535 

689 


Gyn. 

Gyn. 

Gyn. 

Gyn. 

Gyn. 

Gyn. 

Gyn. 

Gyn. 

Gyn. 

Gyn. 

Gyn. 

Gyn. 

Gyn. 

Gyn. 

Gyn. 

Gyn. 

Gyn. 

Gyn. 

Gyn. 

Gyn. 

Gyn. 

Gyn. 

Gyn. 

Gyn. 

Gyn. 

Gyn. 

Gyn. 

Gyn. 

Gyn. 

Gyn. 

Gyn. 

Gyn. 

Gyn. 

Gyn. 

Gyn. 

(iyn. 
I  G 
i  ( 

( 

( 

( 
,  ( 


No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

N( 

N( 

N( 

N( 

N 

N( 

No 

N( 

N( 

Xi 

N( 

X( 

N. 

X( 

Xt 


1872 681 

1879 457 

191() 570 

1946 384,625 

1949 504,505 

1966 448 

2005 445 

2039 546,548 

2042 435.568 


448 

661 

376 

666 

465 

2129 463,658 


2052. 
2070. 
2073. 
2098. 
2108. 


2142... 
2158... 
2172... 
2182... 
2183... 
2189... 
2291 . .  . 
2432. . . 
2434... 
2500... 
2570. . . 
2593... 
259S... 
2()()()..  . 
2634... 


592 
448 
346 

587 
585 
570 


.  .  . .  270 
.433,652 
.547, 570 
9 
.573,587 
.548.658 
.  . . .  444 
405 


2658 314.315 

2666 587 

2691 7,631 

2699 432,658 

2706  ...311,387,659 

2709.^ 443,558 

2710 .■)17.()()1 

2713  ...451,630,671 

27-14 l.')3 

2746 132 

2754 374 

2763a 356,462 


()<)() 


IXDKX    OF    GYXECOLOCICAI.    XIMBKRS. 


PA<:i; 
Gyn.  No.  IITI  .      1  tS,  4()_'.  547 

Gyn.  No.  2777 367 

Gyn.  No.  2800 302,  436 

Gyn.  No.  2806 463,  661 

Gyn.  No.  2822 366 

Gyn.  No.  2838 448 

Gyn.  No.  2852  ...  1 24 .  3 1 7 .  32.-> 
Gyn.  No.  2873 71..")73. 

575. 581 

Gyn.  No.  2SS1 11 

Gyn.  No.  2899 378.  381, 

382.436 

Gyn.  No.  2902 457 

Gyn.  No.  2919 306.658 

Gyn.  No.  3008 8,  308,  313, 

320.349,674 

Gyn,  No,  3014 12(1,  132 

Gyn,  No,  303S  .  .  .318,321.327 
Gyn,  No,  3066 448,  453, 

573 , 574 

Gyn,  No.  3107 84 

Gyn.  No.  3111 308,448 

Gyn.  No.  3113  .  .  .76,  123,  247, 

294.317.329,371,385,438, 

466 

(iyn.  No,  3119 630 

(iyn.  No.  3130 132,  328 

Gyn.  No.  3133  .  .  76,  164,  166, 

304,307,324.332.376,379, 

387 

(Jyn,  No.  3154 443 

Gyn.  No.  3198 469,674 

Gyn.  No.  3199  ...154,302,449 

Gyn.  No.  3209 322 

Gyn.  No.  3216  .  . .  .86.  137,320 

Gyn.  No.  3218 314 

Gyn.  No.  3232 323.324 

Gyn.  No.  3272 382 

Gyn.  No.  3281 . .  .319,  380,  436 

Gyn.  No.  3293 315 

Gyn.  No.  3294 351 

Gyn.  No.  3295  . .  .248.  280,  585 
Gyn.  No.  3296  ....  19.  154.  355 
Gyn.  No.  3319  .  .  335,336.371 
Gyn.  Xo.  .3320 165.  166, 

332,659 

Gyn.  No.  3338 449,6.30 

Gyn,  No.  3340 132,  333, 

136,603 

Gyn,  No.  3345 102 

Gyn.  No.  3349 104,303 

Gyn,  No,  3353 449 

Gyn,  No,  3357 158 

Gyn.  No.  3385. .  .320,  321,  431 
Gyn,  No,  3387 33,469 


P.\GE 

(Jyn.  No.  3394 436 

Gyn.  No.  3408 332 

Gyn.  No.  3416 462 

Gyn.  No.  3418 302 

Gyn.  No.  3426 436,581 

Gyn.  No.  3437 324,457 

Gyn.  No.  3440  .  .  .436.464,631 

Gyn.  No.  3444 451 

Gyn.  No.  .3445  .  .  .370.657,666 
Gyn.  No.  3449 158.  314, 

4.36.661 

Gyn.  No.  3461 254 

Gyn.  No.  3488 158 

Gyn.  No.  3490 398 

Gyn.  No.  3491 307 

Gyn.  Xo.  3492 31S,  654, 

(i()S,669 
Gyn,  No,  3493 298,  441> 

674,676 

Gyn,  No,  3504A 105 

Gyn.  No.  3508 582 

Gyn.  No.  3535 661 

Gyn.  No.  3558 18 

Gyn.  No.  3583 449 

Gyn.  No.  3590 371,385 

Gyn.  No.  3600 511 

Gyn.  No.  3614  .  .  .312,  663,  664 

Gyn,  No,  3693 489 

Gyn.  No.  3774 436 

Gyn.  No.  3778 132 

Gyn.  No.  3842 50,372 

Gyn.  No.  3844 132 

Gyn.  No.  3882 674,  676 

Gyn.  No.  3985 132 

Gyn.  No.  3898 674,  675 

Gyn.  No.  3918 661 

Gyn.  No.  3950 17.132 

Gyn.  Xo.  3960 317.349 

Gyn.  No.  3971 55.  379 

Gyn.  No.  3974 18 

Gyn.  No.  3977 654.  681 

Gyn.  No.  3985 3 

Gyn.  No.  3991 97 

Gyn.  No.  3997 654 

Gyn.  No.  4016 449.527 

Gyn.  No.  4020 348.  349, 

.368.. 369 
Gyn.  Xo.  4022 352.  36S, 

369.668 
(iyn.  No.  4055  ...511,  546,  570 

Gyn.  No.  4097 387,  (531 

Gyn.  No.  4160 132,  .570 

Gyn,  No,  4165 587 

Gyn,  No,  4168 380.448 

Gyn.  No.  4172 659 


P.^GE 

Gyn.  No.  4193..  ......663,664 

Gyn.  No.  4203 323,  447 

Gyn.  No.  4252 359 

Gyn.  No.  4262 287 

Gyn.  No.  4285 457 

Gyn.  No.  4297 509 

Gyn.  No.  4314 77 

Gyn.  No.  4340 365 

Gyn.  No.  434L 1.32 

Gyn.  No.  4364 129.132 

Gyn.  No.  4365 517 

Gyn.  No.  4369 666 

Gyn.  No.  4370 387,441 

Gyn.  No.  4372 666 

Gyn.  No.  4,382  .  .  .435.  571,  579 
Gyn.  Xo.  4415  .  S9,  511,  554, 

555 

Gyn.  No.  4441 441 

Gyn.  No.  4471 527 

Gyn.  No.  4485 116 

Gyn.  No.  4517 559 

Gyn.  No.  4526 448 

Gyn.  No.  4537 552 

Gyn.  No.  4599 377,451 

Gyn.  No.  4607 265 

Gyn.  No.  4609  . .  .358,  673,  674 

Gyn.  No.  4607 678 

Gyn.  No.  4617 436.  666 

Gyn.  No.  4635 ()03 

Gyn.  No.  4663 572,  586 

Gyn.  No.  4699 495 

Gyn.  No.  4731 441,623 

Gyn.  No.  4732 341 

Gyn.  No.  4761 368 

Gyn.  No.  4771 352 

Gyn.  No.  4794 579 

Gyn.  No.  480 U .  .  130.  132.460 

Gyn.  Xo.  4814 570 

(iyn.  Xo.  4828  .  .  .386.  449,619 

Gyn.  No.  4832 366,603 

(iyn.  Xo.  4844  .  .  .  509,  568,  570 

( iyn.  Xo.  4856 525 

(iyn.  No.  4869 359,  657 

Gyn.  No.  4870 631 

Gyn.  No.  4873 548 

Gyn.  No.  4877 456 

(iyn.  No.  4894 668 

(iyn.  No.  4902 666,668 

Gyn.  No'.  4903 456,  666 

Gyn.  No.  4925  .77,  511,  519, 

562 

(iyn.  No.  4929 546 

(Jyn.  No.  4955  .  .  .327,  (565,  666 

Gyn.  No.  4959 446 

Gyn.  No.  4965 335,  336 


INDEX    OF    GYNECOLOGICAL    NIMBEKS. 


691 


Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 

Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 

Gyn. 
Gyn. 
Gyn. 
Gyn. 
Gyn. 


No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 

No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 

No. 
No. 
No. 
No. 

No. 


.  461 


PAGE 
',075 

448 

132 

529 

. .10.453,678 
.387,388,448 

560 

530 

511 


4967. 
4972. 
4975. 
4990. 
5010 
5014 
5076. 
5081 . 
5086. 

5092 398,461 

5093 663 

5103 363,626 

5123 461,639 

5124 542 

5133 585 

5141 355,441 

5153 507,517 

5193 623 

5239 603 

5242 574,586 

5249 391 

5277 603 

5279 507 

5289 448 

5296  ...574,579,587 
5302  ...390,674,676 

5303 132,568 

5325 387,603 

5332 510 

5359 510,  546, 

550, 553 

5421 376 

5447  ...509,512,520 
5452  .  ..509,517,546 
5493  ...507,509,520 
5496  ...252,579,586 

5528 295,348 

5560 553 

5588 547 

5614 509 

5617  ...148,307,678 
5622 579 


558 
536 
78 
372 
587 
5697 371,391 


5635. 
5638. 
5644. 
5647. 
5687. 


.orA 


5734. 

5752. 
5766. 
5784 . 
5801 . 
5808. 


.306,  351, 
352,623 

53 

666 

. .. .27,78 

548 

333 


PAGE  ' 

Gyn.  No.  5826 511,  552,  Gyn.  No. 

554,568  Gyn.  No. 

Gyn.  No.  5843 441  Gyn.  No. 

Gyn.  No.  5846 439,  560  Gyn.  No. 

Gyn.  No.  5858 283,  658,  Gyn.  No. 

674,676  Gyn.  No. 

Gyn.  No.  5871 462  Gyn.  No. 

Gyn.  No.  5871^ 579  Gyn.  No. 

Gyn.  No.  5873 554  Gyn.  No. 

Gyn.  No.  5907 252  Gyn.  No. 

Gyn.  No.  5943. 441  Gyn.  No. 

Gyn.  No.  5946  .  .78,329,  330,  i  Gyn.  No. 

375,  436  I  Gyn.  No. 

Gyn.  No.  5957 284  Gyn.  No. 

Gyn.  No.  5965 569  Gyn.  No. 

Gyn.  No.  5987 391  Gyn.  No. 

Gyn.  No.  5993 147  Gyn.  No. 

Gyn.  No.  6002 85,  587  Gyn.  No. 

Gyn.  No.  6017  .  .  .379,451,679  Gyn.  No. 

Gyn.  No.  6036 663  |  Gyn.  No. 

Gyn.  No.  6039 663  Gyn.  No. 

Gyn.  No.  6045 223 

Gyn.  No.  6047 507  Gyn.  No. 

Gyn.  No.  6070 569  Gyn.  No. 

Gyn.  No.  6129 354,462 

Gyn.  No.  6143 587  I  Gyn.  No. 

Gyn.  No.  6145 570  i  Gyn.  No. 

Gyn.  No.  6169 299  Gyn.  No. 

Gyn.  No.  6178 370,623  Gyn.  No. 

Gyn.  No.  6185  .  .  .422,  426.  582  Gyn.  No. 

Gyn.  No.  6190 355  I  Gyn.  No. 

Gyn.  No.  6198 441,619  Gyn.  No. 

Gyn.  No.  6199 391  Gyn.  No. 

Gyn.  No.  6206 622  Gyn.  No. 

Gyn.  No.  6217 677  I  Gyn.  No. 

Gyn.  No.  6240 442  Gyn.  No. 

Gyn.  No.  6272  .  .  .  .32,  4.")3.  626  Gyn.  Xo. 

Gyn.  No.  6324 42  (lyn.  No. 

Gyn.  No.  6330 270  Gyn.  No. 

Gyn.  No.  6344  .  .  .347,  348,  382  Gyn.  No. 

Gyn.  No.  6372 (i()3,  ()66  Gyn.  No. 

Gyn.  No.  6376 446 

Gyn.  No.  6381 .338,  446  ( lyii.  No. 

Gyn.  No.  6395 507.  51  7  ( iyii.  .NO. 

Gyn.  No.  6407 257  ( \\\\.   No. 

Gyn.  No.  6418 33,381  (iyii.  N.i. 

Gyn.  No.  6432 116,  464  (lyn.  Xo. 

Gyn.  No.  6433 61  |  Gyn.  Xo. 

Gyn.  No.  6439 408  | 

Gyn.  No.  6441 146.  151 .  Gyn.  No. 

579,  .')S7  Gyn.  No. 

Gyn.  No.  6474 550.  555  Gyn.  Xo. 

(;yn.  No.  6479 1.30,  132,  Gyn.  No. 

332.348  Gyn.  No. 

Gyn.  No.  6.")0S 648  | 


PAGE 

6521 447.677 

6570 78 

6582 370 

6604  ....576,579,587 

6607 .387,388 

6610 388 

6615 453 

6628 463 

6667  ...320,3.57,367 
6722  ...452,463,621 
6724  ...222,  ,546,  547 

6760 566,570 

6762 510,550 

6773 525,569 

6774 44 

6781 508 

6791 625 

6792  ...465,622.669 
6833  ...132,579,587 

6843 59,452 

6855  .. .68,439,  578, 
587 

6863 3.-)5,368 

6915  .  .362.372,  622, 
632.666 

6933 669 

6950 570 

6972 603 

6991 .336,464 

6997 669,681 

010 587 

Oil 464 

014 452 

025 509 

029 509 

036 .")66.679 

010  212 

049  .  .  .1(),S.;^72,385 

O.')0 .")7 1,579 

063 343.376 


064. 

()7:> 
O.SC) 
1  ( )•_' 
120. 
133. 
1 58 . 

l.")9 
ISl 
2 1 2 
216. 
218. 


355.  .368, 
620,621 
.■>.')9.."0 

■_'(•.  I 

115 

.    622 


l.")0.  15(i. 

673.674 

.509,. 568 

3X5.6.36.637 
212 

4.52 

570 


692 


LXDKX    OF    GYNECOLOGICAL    NUMBERS. 


PAGE 

Gyn.  Xo.  7220 21 ,  437,  Gyn 

508, 546  Gyn 

Gyn.  Xo.  7226  ....  44, 158, 366  Gyn, 

Gyn.  Xo.  7237 354.  631,  Gyn. 

663,664  Gyn. 

Ciyn.  Xo.  7240 58,  452,  CJyn. 

657,658,660  Gyn. 

Gyn.  Xo.  7263 496  Ciyn. 

Gyn.  Xo.  7266 452,  621  Gyn. 

Gyn.  X^o.  7276 621  Gyn. 

Gyn.  Xo.  7295 452,  463  Gyn. 

Gyn.  Xo.  7313  ....  67, 195, 355  Gyn. 

Gyn.  Xo.  7330 654  Gyn. 

Gyn.  Xo.  7361 439,  680  Gyn. 

Gyn.  Xo.  7381 669, 681  Gyn. 

Gyn.  Xo.  7383 69,  572  '  Gyn. 

Gyn.  Xo.  7438 453 ,  465  Gyn. 

Gyn.  Xo.  7441 441  Gyn. 

Gyn.  Xo.  7460.  .  .436,461,659  Gyn. 

Gyn.  Xo.  7474  . .  .208, 621, 683  Gyn. 

Gyn.  Xo.  7511 93  Gyn. 

Gyn.  Xo.  7528 355 

Gyn.  Xo.  7549  . .  .  .65,  69,  142,  Gyn. 

461,613  ,  Gyn. 

Gyn.  Xo.  7560 536, 658  Gyn. 

Gyn.  X"o.  7566 558  Gyn. 

Gyn.  Xo.  7.")69 452.  453,  Gyn. 

665.666  Gyn. 

Gyn.  Xo.  7583 376,623  Gyn. 

Gyn.  Xo.  7597 381  Gyn. 

Gyn.  Xo.  7600 440 

Gyn.  Xo.  7604 220,  685  Gyn. 

Gyn.  Xo.  7615  ....  64,  300.  4,">4  Ciyn. 

Gyn.  Xo.  7630  . .  .365,  370,  452  Gyn. 

Gyn.  Xo.  7688 452, 462 

Gyn.  Xo.  7695 78  Gyn. 

Gyn.  Xo.  7696 603  Gyn. 

Gyn.  Xo.  7699  . . .  280, 329,  585  Gyn. 

Gyn.  Xo.  7703 603,  658,  Gyn. 

661,662  Gyn. 

Gyn.  Xo.  7721 570  Gyn. 

Gyn.  Xo.  7739  .  .  .  .49,  619,  631  Gyn. 

Gyn.  Xo.  7753 550  Gyn. 

Gyn.  Xo.  7775  .  . .  132,  345,  346  Gyn. 

Gyn.  Xo.  7779 563  Gyn. 

Gyn.  Xo.  7795  . . .  132,  325,  342  Gyn. 

Gyn.  Xo.  7819 267  Gyn. 

Gyn.  Xo.  7849 342  Gyn. 

Gyn.  Xo.  7859  . . .  359, 452, 660  Gyn. 

Gyn.  Xo.  7863 674  Gyn. 

Gyn.  Xo.  7872 570 

Gyn.  Xo.  7886  ...  548,  564,  661  Gyn. 

Gyn.  Xo.  7889 130,  132  Gyn. 

Gyn.  Xo.  7978 521  Gyn. 

Gyn.  Xo.  7992 295  Gyn. 


PAGE 

Xo.  8008 439,636 

Xo.  8024 363,681 

Xo.  8089 547 

Xo.  8106 441 

Xo.  8114 594 

Xo.  8115 387 

Xo.  8147 414 

Xo.  8159 571,587 

Xo.  8183 681 

Xo.  8197 465 

Xo.  8220 336 

Xo.  8251 496 

Xo.  8259 548,661 

Xo.  8264 391 

Xo.  8266 449 

Xo.  8270 127,132 

Xo.  8294 668 

Xo.  8306 460,603 

Xo.  8310 508 

No.  8321 382,666 

Xo.  8354 319,  320, 

330, 461 

Xo.  8368 328,451 

Xo.  8371 362 

Xo.  8389  ...511,550,554 

Xo.  8391 380,381 

Xo.  8410 64,586 

Xo.  8415 510,562 

Xo.  8437 371 

Xo.  8462 447,  516, 

517, 550 

Xo.  8476 546,547 

Xo.  8477 244 

Xo.  8495 60,  452, 

460,656 

Xo.  8514 465 

Xo.  8517 587 

Xo.  8526 354 

Xo.  8593 683 

Xo.  8600 587 

Xo.  8610 231,360 

Xo.  8667 465 

Xo.  8675 348 

Xo.  8690 619 

Xo.  8693 334 

Xo.  8698 447,570 

No.  8705 603 

Xo.  8713  ...363,465,684 

Xo.  8726 509 

Xo.  8732 1.30.  132, 

215,674 

Xo.  8738 309,390 

Xo.  8764 554,  555 

Xo.  8767 146 

Xo.  8773 517,553 


Gyn 

Xo 

Gyn 

Xo 

Gyn 

Xo 

Gyn 

No 

Gyn 

Xo 

Gyn 

No 

Gyn 

Xo 

Gyn. 

Xo. 

Gyn 

Xo 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

xXo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

No. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

Gyn. 

Xo. 

P.^GE 

.  8804  ...454,456,584 

,  8831 587 

,  8836... 229, 373, 684 
8844  ...439,509,546 

,8866 356 

8872 684 

8882 112 

8897 531 

8936 60,  454, 

455,  565 

8943 449 

8951 454,670 

8963 455 

8985 341.342 

8990 342 

9004 266 

9012 290 

9013 448 

9024 511,569 

9027 43 

9029 603 

9030  ...346,496,679 

9057 376,437 

9078 45,  456 

463.603 

9090 351,494 

9107 502 

9118  ...237,507,511 

9132 326,683 

9137 576,587 

9138 451 

9141 289 

9196 585 

9197 509 

9203  ....60,454,565 

9215 570 

9221 547 

9243  ...342,526,568 

9286 603 

9304 546. 

9329...  555,  568,569 

9439 562 

9443 277 

9457 348,349, 

379,462 

9470 569 

9527 603 

9536 180,683 

9540 40 

9593 451,  454,. 

455, 456 

9608 498 

9629 517 

96.36 336 

9637  ...434,435.507 


IXDKX    OF    GYXKCOLOGICAL    NTMRKRS. 


693 


PAGE 

Gyn.  No.  9638 572 

Gyn.  No.  9652 435,681 

Gyn.  No.  9674 51 

Gyn.  No.  9675 360, 680 

Gyn.  No.  9678  . .  .451,454,609 

Gyn.  No.  9694 387 

Gyn.  No.  9707 327,  451, 

454, 457 

Gyn.  No.  9736 496,  654 

Gyn.  No.  9767 352 

Gyn.  No.  9769 63,452 

Gyn.  No.  9780 56 

Gyn.  No.  9786  . .  .31,  451,  454, 

455, 457 

Gyn.  No.  9788 603 

Gyn.  No.  9798  ....  57, 376,  594 

Gyn.  No.  9818 603 

Gyn.  No.  9843 603 

Gyn.  No.  9875 572,  587 

Gyn.  No.  9924 94,449 

Gyn.  No.  9928 451,603 

Gyn.  No.  9934 293 

Gyn.  No.  9953 445 

Gyn.  No.  9971 658 

Gyn.  No.  10059 546,  547 

Gyn.  No.  10085 291 

Gyn.  No.  10095  .  .349,  681,682 

Gyn.  No.  10102 352 

Gyn.  No.  10164 660 

Gyn.  No.  10172 454, 455 

Gyn.  No.  10183 560 

Gyn.  No.  10194 657 

Gyn.  No.  10199 451 ,  666 

Gyn.  No.  10204 373,  381, 

496,669 

Gyn.  No.  10211 666 

Gyn.  No.  10220 278 

Gyn.  No.  10229 666 

Gyn.  No.  10237 340, 341 

Gyn.  No.  10257 518,  568 

Gyn.  No.  10281 666 

Gyn.  No.  10287 669 

Gyn.  No.  10300  .  .517,  547,  548 
Gyn.  No.  10314  .  .  155,  578,  579 

Gyn.  No.  10323 666 

Gyn.  No.  10337 426,  427 

Gyn.  No.  10351 509,  510, 

517,537 

Gyn.  No.  10357 604,  666 

Gyn.  No.  10376 183,  572, 

579, 586 
Gyn.  No.  10394 509.  546, 

.')47,5.")0 

Gyn.  No.  10103 2 

Gyn.  No.  10426 669 


PAGE 

Gyn.  No.  10440 488 

Gyn.  No.  10453 604 

Gyn.  No.  10462 279 

Gyn.  No.  10479 509,  568 

Gyn.  No.  10486 677 

Gyn.  No.  10490 486, 487 

Gyn.  No.  10491 351,495 

Gyn.  No.  10497 548 

Gyn.  No.  10555 445,  495, 

663,664 

Gyn.  No.  10558; 604 

Gyn.  No.  10573 517,  555 

Gyn.  No.  10580 604 

Gyn.  No.  10587 526,  547 

Gyn.  No.  10588  .  .518,  537,  538 

Gyn.  No.  10593 681 

Gyn.  No.  10618  .  .457,  579,  589 

Gyn.  No.  10635 579,  587 

Gyn.  No.  10667 604 

Gyn.  No.  10669 363,674 

Gyn.  No.  10749i  .391,674,675 

Gyn.  No.  10778 667 

Gyn.  No.  10872 572,  586 

Gyn.  No.  10875 346, 667 

Gyn.  No.  10916 307,373 

Gyn.  No.  10917 340 

Gyn.  No.  10969 436, 659 

Gyn.  No.  10983 547,  549 

Gyn.  No.  10991 376 

Gyn.  No.  10995 594 

Gyn.  No.  10997 281 

Gyn.  No.  11000 568 

Gyn.  No.  11010 572 

Gyn.  No.  11013  .  .373,377,457 
Gyn.  No.  1 1052  . .  546,  547,  555 

Gyn.  No.  11067 78, 462 

Gyn.  No.  11110 539 

Gyn.  No.  11111 569 

Gyn.  No.  11133 497 

Gyn.  No.  11139 454 

Gyn.  No.  11169 518 

Gyn.  No.  11180 366,  669, 

681 , 682 

Gyn.  No.  11216 604 

Gyn.  No.  11217 604 

Gyn.  No.  11224 74 

Gyn.  No.  11243  .  .446,  572,  587 

Gyn.  No.  11251 463 

Gyn.  No.  11256 511,549 

Gyn.  No.  11293 266 

Gyn.  No.  11294 661 

Gyn.  No.  11296 542 

Gyn.  \().  11337 426.  427, 

454, 455 
Gyn.  No.  1 1392  .  .419,  463.  601 


PAGE 

Gyn.  No.  11422 370 

Gyn.  No.  11428 341 

Gyn.  No.  11472 604 

Gyn.  No.  11572 157 

Gyn.  No.  11587 376 

Gyn.  No.  11630 350 

Gyn.  No.  11634 622 

Gyn.  No.  11647 388 

Gyn.  No.  11681 604 

Gyn.  No.  11688 604 

Gyn.  No.  11694 155 

Gyn.  No.  11722 604 

Gyn.  No.  11792 133 

Gyn.  No.  11869 669 

Gyn.  No.  11889.  .454,455,  572, 

577, 579, 587 

Gyn.  No.  11898  ..15,128,133 

Gyn.  No.  11919 625 

Gyn.  No.  11927 435 

Gyn.  No.  11944 232,  442, 

443,451,591 

Gyn.  No.  11949 258 

Gyn.  No.  11984 462, 604 

Gyn.  No.  11989 88,383 

Gyn.  No.  12000 392, 448 

Gyn.  No.  12021 329 

Gyn.  No.  12028 ^o^^,  569 

Gyn.  No.  12034 346,  527 

Gyn.  No.  12036.  .440,  462.  ;511 

Gyn.  No.  12041 348 

Gyn.  No.  12056 263 

Gyn.  No.  12079 579,586 

Gyn.  No.  12086 306, 604 

Gyn.  No.  12119 336 

Gyn.  No.  12139  . .  257, 302, 619 
Gyn.  No.  12154 449.  451, 

665,667 
Gyn.  No.  121.-)5  .  .200,332,461 

Gyn.  No.  12165 452,  527 

Gyn.  No.  12185 604 

Gyn.  No.  12194 49.669 

Gyn.  No.  12199 666, 667 

Gyn.  No.  12209 674. 675 

Gyn.  No.  122ir) 135,  435, 

447.677 

Gyn.  No.  12221 302,303 

Gyn.  No.  12234 332.  451, 

4.V2.454 
Gyn.  No.  12257  ..572,579,587 

Gyn.  No.  12291 465 

Gyn.  No.  12293 376, 452 

Gyn.  No.  12297 260 

Gyn.  No.  12301 604 

Gyn.  No.  12.323 577 

(ivn.  No.  12369  .  .449.  I(i3.  604 


694 


IXDKX    OF    OYXKCOLOCICAL    NUMBERS. 


Gyn.  No.  123S0 842 

Gyn.  No.  12439 (iOO 

Gyn.  No.  12452 UiU 

Gyn.  No.  12488 604 

Gyn.  No.  12490 323 

Gyn.  No.  12504 555,  556 

Gyn.  No.  1 2520 387 

Gyn.  No.  12522 103,  604 

Gyn.  No.  12525 604 

Gyn.  No.  12583 547,  552 

Gyn.  No.  12585 511 

Gyn.  No.  12587 648,  674, 

680,682 
Gyn.  No.  12591  .491,571,586 

Gyn.  No.  12611 681 

Gyn.  No.  12656 417 

Gyn.  No.  12681 438,439 

Gyn.  No.  12689 563 

Gyn.  No.  12696 604,661 

Gyn.  No.  12709 81 

Gyn.  No.  12725 270,  459 

Gyn.  No.  12738 668 

Gyn.  No.  12764 604,661 

Gyn.  No.  12779 133,388 

Gyn.  No.  12788 243 

Gyn.  No.  12811 446,667 

Gyn.  No.  12841 387 

Gyn.  No.  12852 509,  525 

Gyn.  No.  12864  ,  .97,  239,373, 

436 

Gyn.  No.  12866  .  .336, 341 ,  384 

Gyn.  No.  12890 454 

Gyn.  No.  12902 649 

Gyn.  No.  12912 346 

Gyn.  No.  12937 604 

Gyn.  No.  12944 604 

Gyn.  No.  12964 452 

Gyn.  No.  13014 579,587 

Gyn.  No.  1.3015 271 

Gyn.  No.  I.'^OIC. 376,  449, 

681 , 682 

Gyn.  No.  1.3025 362,452 

Gyn.  No.  13039 23,  452, 

4.>3,601 

Gyn.  No.  13056 263 

Gyn.  No.  1.3067 74 

Gyn.  No.  13204 4S2 

Gyn.  No.  13272 474 

Gyn.  No.  13423 121 

Gyn.  No.  13498 487,  488 

Gyn.  No.  13625 118 

Gyn.  No.  1,3626 438 

Gyn.  No.  13629 368 

Gyn.  No.  14373 310 

Gyn.  No.  14662 687 


P.\GE 

(lyn.  No.  14709 30 

Gyn.  No.  14942 145 

Gyn.  No.  15252 687 

i  Gyn.  No.  15281 139 

Gyn.  No.  15283 51 

Gyn.  No.  15477 687 

B.  H.,  Dec.  5,  1908 362 

San.  No.  471 240 

San.  No.  581 2.56 

San.  No.  577 249 

San.  No.  836 163 

San.  No.  858 339 

San.  No.  941 87 

San.  No.  1011 101 

San.  No.  1049.  .  .  .374,436,631 

San.  No.  1058 363 

San.  No.  1497 587 

San.  No.  1530 2 

San.  No.  1545 568 

San.  No.  1566 677 

San.  No.  1593 586 

San.  No.  1682 680 

San.  No.  1691 604 

San.  No.  1702 604 

San.  No.  1773 604 

San.  No.  1837 4.54,  456 

San.  No.  1847 149  ; 

San.  No.  1852 280  | 

San.  No.  1857 206 

San.  No.  1868 454 

San.  No.  1872. . .  .300,360,681 

San.  No.  1879 204 

San.  No.  1924 94,356 

San.  No.  1925 108 

San.  No.  1944 454,663 

San.  No.  1973 259 

San.  No.  2142 592 

San.  No.  2144 604 

San.  No.  2164 604 

San.  No  217S .564 

San.  No.  2189 133 

San.  No.  2368 339 

r.  H.  I.,  P ,35 

(".  II.  I..  R.  Oct.  25.  1902   62 

C.  H.  I.,  C.  Aujjc.  12,  1902   81 

(".  H.  I.,  W.Jan.  22,  1903  190, 

442,464,511 

('.  II.  I.,  K 286 

C.  H.  I.,  B 355 

C.  H.  I.,  McA.,  .362,  4.36,  512, 

C.  H.  I..  F.  Auii.  10.  1902  120, 

375 

('.  H.  I..  R.Oct.  24,  1902.  382 

C.  H.  I.,  B.April  28,  1904  436 


vw.r. 

C.  H.  I.,  F 461 

C.  H.  I.,  A 464 

C.  H.  I.,  S 468 

C.  H.  I..  M 469 

C.  H.  I.,  Dr.  Ernest  .John- 
ston's Case 480 

C.  H.  I.,  P.  June  17.  1906.   485 

C.  H.  I.,  S.  Feb.  1904 500 

C.  H.  I.,  B 509 

C.  H.  I..  S 509 

C.  H.  I.,  B 510 

C.  H.  I.,S 512 

C.  H.  I.,  H 517 

C.  H.  I.,  W 544 

C.  H.  I.,  8.  June  9,  1903.  .    551 

C.  H.  I.,  G 565 

C.  H.  I.,  Peth 569 

C.  H.  I..  J .587 

C.  H.  I.,  S.  Dec.  15,  1906     .588 

C.  H.  I.,  R ,-,94 

C.  H.  I.,  H.  Mar.  16.  1903  621 
C.  H.  I.,  K.  Mar.  14.  1903  637 

C.  H.  I.,  H 6.36 

C.  H.  I..  H.June,  1903.  .  .    664 

C.  H.  I.,  A 667 

C.  H.  I.,  W 667 

C.  H.  I..  K 674 

C.  H.  I.,  No.  78 184 

C.  H.  I..  No.  .382 604 

C.  H.  I.,  No.  392 452.604 

C.  H.  I.,  No.  409 .587 

C.  H.  I.,  No.  495 38 

C.  H.  I.,  No.  511 681,682 

C.  H.  I..  No.  620    .  .  .105,  604, 
650 

C.  H.  I.,  No.  673 604 

C.  H.  I.,  No.  686 260 

C.  H.  I.,  No.  728 455 

C.  H.  I.,  No.  793 463 

C.  H.  I.,  No.  930 .525 

C.  H.  I..  No.  949 .381,  604, 

(524 

C.  H.  I.,  B.  No.  1019  ...  .  .-)09, 

510.. 525 

('.  H.  I.,  No.  1095 604 

('.  H.  I.,  No.  1201 .-)87 

('.  H.  I.,  No.  1205 439 

C.  H.  I.,  No.  1.3.->2 625 

Ca.se  C,  Hagerstown,  Md. .      24 
Mrs.  B.,  Frederick  Emer- 
gency Ho.spital,  Oct.  30, 

1904 24 

Dr.    J.    Mason    HinuUey's 

case 47 

C.  G.,  Hagerstown.  Mil. ...      .50 


INDKX    OF    GYXKCOLOGirAL    XU.MRKUS. 


()9o 


Dr.  Curtis  Burnani's  case.  70 
Professor     Raffaele     Bas- 

tianelli's  case 79 

Dr.     George     E.     Holtz- 

apple's  case 1.30 

Dr.  Houston.  Troy.  N.  Y., 

case 144 

Dr.  Hunner's  case 175 

Dr.  Paul  Owsley's  case  .  .  276 
Dr.  Homer  Gage's  case.  .  .   335 


P.\  <  i  K 

Ca.se  O..  Hebrew  Hospital.  451 
A.  P.,  Cambridge  Hospital, 

March  4.  1906 470 

Dr.     T.    A.     Erck's    ca.se 

(Philadelphia) 477 

Dr.  James  Bosley's  case  .  .    493 

U.  P.  I " 517 

S.  (Toronto).  June.  1903.  .    534 

Case  G.,  Frederick 531 

O.,  Hebrew  Hospital 551 


r.  P.  I..  G 

J.  I  Kelly),  Dec.  9.  1899... 
A.    \V..  Cambridge.    Md., 

Hospital.  May  24.  1905 
Dr.   E.   A\'.   Meisenhelder, 

York.  Pa..  Jan.  2,1903. 
Dr.  Stansbury  Sutton  .... 

Dr.  Geo.  Ben  Johnston.  .  . 


P.\GE 

565 

588 

641 

686 
643, 

644 
645, 

646 


PATHOLOGICAL  NUMBERS. 


This  list  includes  only  those  cases  that  are  more  or  less  fully  discussed  in  the  text, 
gynecological  numbers  and  the  autopsy  numbers  are  given  in  the  accompanying  lists. 


The 


Path.  No.  101 

Path.  No.  119 

Path.  No.  162 

Path.  No.  178 

Path.  No.  186 433 

Path.  No.  196 

Path.  No.  204 

Path.  No.  213 314 

Path.  No.  222 

Path.  No.  245 

Path.  No.  246 

Path.  No.  256 

Path.  No.  2.59 

Path.  No.  265* 

Path.  No.  266 

Path.  No.  276 

Path.  No.  286 

Path.  No.  312 5 

Path.  No.  347....  124, 317 

Path.  No.  359 

Path.  No.  380 

Path.  No.  435.. 8,. 308, 313 

Path.  No.  443 126 

Path.  No.  452  ..  .318,321 

Path.  No.  460 

Path.  No.  472 

Path.  No.  479 5,. 308 

Path.  No.  487.... 76,  123, 

329, 247 

Path.  No.  494.... 76,  164, 

303..304,305,307,324 

Path.  No.  499 5,132 

Path.  No.  .524.. 5,  154,302 

Path.  No.  5.33 313 

Path.  No.  534 86,137 

Path.  No.  539 

Path.  No.  540 

Path.  No.  .543 323 

Path.  No.  573 

Path.  No.  ,580 

Path.  No.  582 248 

Path.  No.  583 

Path.  No.  589  .5,165,166 


P.'V.GE 

270 

270 

9 

68 

,652 

309 

405 

,315 

405 

311 

432 

309 

5 

7 

68 

132 

356 

,302 

,325 

4,7 

306 

,320 

,132 

,327 

68 

84 

,309 

317, 

,294 

166, 

,  .332 

,  328 

,318 

,469 

,320 

314 

322 

,324 

319 

19 

,  280 

315 

,332 


PAGE 

Path.  No.  591 312 

Path.  No.  592 309,336 

Path.  No.  605 144 

Path.  No.  607 5,132,333 

Path.  No.  610 104,303 

Path.  No.  616 102 

Path.  No.  618 158 

Path.  No.  6.34  .  .  .320,321,431 

Path.  No.  641 33 

Path.  No.  659 .332 

Path.  No.  661 302 

Path.  No.  674 5,7 

Path.  No.  682 254 

Path.  No.  683 158,314 

Path.  No.  707 158 

Path.  No.  711 318 

Path.  No.  713 307 

Path.  No.  715 298 

Path.  No.  719 105 

Path.  No.  740 643, 644 

Path.  No.  742 18 

Path.  No.  788 312 

Path.  No.  828 489 

Path.  No.  872 132 

Path.  No.  910 132 

Path.  No.  964 5 

Path.  No.  970 132 

Path.  No.  971 318,349 

Path.  No.  977 55 

Path.  No.  980 18 

Path.  No.  986 3,132 

Path.  No.  990 97 

Path.  No.  1009 369 

Path.  No.  1012 369 

Path.  No.  1084 132 

Path.  No.  1116 323 

Path.  No.  1137 287 

Path.  No.  1152 309 

Path.  No.  1165 132 

Path.  No.  1170 129,132 

Path.  No.  1207 89 

Path.  No.  1245 116 

Path.  No.  1304 2C)5 

697 


Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
I'atli. 


P.\GE 

No.  1307 358 

No.  1318 358 

No.  1327 66,68 

No.  1382 326 

No.  1392 132 

No.  1434 359 

No.  1484 327 

No.  1499 3.36 

No.  1500 132 

No.  1521 529 

No.  1536 10 

No.  1599 147 

No.  1628 529 

No.  1631 398 

No.  1750 68 

No.  1755 132 

No.  1815 240 

No.  1899 252 

No.  1962 148,307 

No.  1973 252 

No.  1990 628 

No.  2034 306,351 

No.  2055 53 

No.  2101 333 

No.  2146 283 

No.  2222 252 

No.  22.38 284 

No.  2242 329,330 

No.  2275 85 

No.  2311 223 

No.  2314 223 

No.  2372 256 


No.  2402, 
No.  2413. 
No.  2426. 
No.  2441. 
No.  2.530. 
No.  25.38. 


249 

6S 

299 

.(58,422..-)82 

32 

306 


No.  2.584 270 

No.  2.-)92 347 

No.  2().-)3 61 

No.  2()()1 116 

No.  2700 132.332 


698 


PATHOLOGICAL    XrMHKRS. 


Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Patli. 
Patli. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 
Path. 


No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 


2808, 

2900. 

2946. 

30 -)2 

307.')^ 

3080 


411 

.320,3.-)7 


r>m 

132 

,')<) 

3170 632 


3177. 
3277. 
3312 
.331.') 
3318. 
3354. 
3373. 
3390. 
3431. 
3472. 
3476. 
3486 


6S 

33() 

212 

56() 

108 

343 

264 

2(i4 

loO 

212 

21 

,44.158.159 


3491 68,69 

3502 58 

3576 68,  195 

3601 4 

3635 69 

3673 67.68,195 

3674 316,588 

3703 162,163 

3706 339 

3729 208 

3757 93 

3799 65,69,142 

3865 220 

3879 64,300 

3948  , .248,280,329 

4043 132,345 

4055 132,325 

4074 267 

4090 353 

4113 87 

4122 359 

4136 132 

4252 35!» 

4403 336 

4453 132 

4479 2X6 

4508 101 

4539  ,  ,319,320.330 


4554, 
4576, 
4593, 
4616, 
4672, 
4716, 
4823 , 


328 

511 

(i  1 

363 

244 

60 

231 

4851 480, 482 


PA  HE 

Path 

No. 

4878 

,  ,  , ,    499 

Path. 

Patli 

No. 

489S 

,  ,    334 

Path. 

Path 

No. 

4931 

.132,215 

Path. 

Path 

No. 

4935 

,389,390 

Path. 

Path 

No. 

4959 

,146,313 

Path. 

Path 

No. 

5032 

, , , ,    229 

Path. 

Path 

No. 

5072 

,111,112 

Path. 

Patli 

No. 

5159 

,  ,  .  ,    3  11 

Path. 

Path 

No. 

5176 

266 

Path. 

Path 

No. 

5180 

, , . .    290 

Path. 

Path 

No. 

5223 

. , . ,    266 

Path. 

Path 

No. 

5234 

. , ,45,47 

Path. 

Path 

No. 

5247 

, , , .    494 

Path. 

Path 

No. 

5265 

...    502 

Path. 

Path 

No. 

5274 

, , , .    237 

Path. 

Path 

No. 

5286 

....   326 

Path. 

Path 

No. 

5312 

....   289 

Path. 

Path. 

No. 

5378 

....      60 

Path. 

Path 

No. 

5471 

....   395 

Path. 

Path. 

No. 

5671 

....    277 

Path. 

Path. 

No. 

5730 

, , . .    180 

Path. 

Path 

No. 

5799 

, , , ,    498 

Path. 

Path. 

No. 

5816 

,131,133 

Path. 

Path. 

No. 

5825 

,  .  . ,    336 

Path. 

Path. 

No. 

5870 

.360,361 

Path. 

Path. 

No. 

5912 

...    327 

Path. 

Path. 

No. 

5982 

, , . .      63 

Path. 

Path. 

No. 

5996 

,  .  .  .      56 

Path. 

Path. 

No. 

6013 

....      57 

Path. 

Path. 

No. 

6046 

....    120 

Path. 

Path. 

No. 

6118 

,..94,96 

Path. 

Path. 

No. 
No. 

No. 

6127 

...    293 

Path. 

Pnth 

6226 

, , . .      62 

Path. 

Path. 

6275 

....    291 

Path. 

Path. 

No. 

6299 

....    352 

Path. 

Path. 

No. 

6418 

, , . ,    278 

Path. 

Path. 

No. 

6421  ,133, 

190,  442, 
464 

Path. 
Path. 

Patli. 

No. 

6430 

, . . .    340 

Path. 

Path. 

No. 

6479 

2 

Path. 

Path. 

No. 

6531 

,  ,  .  ,    155 

Path. 

Palli. 

No. 
No. 

6596 

,  ,  ,  .    183 

Path. 

Path. 

6618 

2 

Path. 

Path. 

No. 

6644 

488 

Path. 

P;itli 

No. 
No. 

6685 

279 

Path. 

P.ilh. 

6712 

....    495 

Path. 

Path. 

No. 

6727 

. , . .    486 

Path. 

Path. 

No. 

6730 

, , . .    279 

Path. 

Path, 

No. 

6811 

, , , ,    276 

Path. 

Path. 

No. 

6908 

, , .    363 

Path. 

Path. 

No. 
No. 

6920 

54 

P.-ith, 

Path. 

7089 

1 53 

Path. 

Path. 

No. 

7162 

307 

Path. 

Path. 

No. 

7192 

549 

Path. 

Path. 

No. 

7246 

....    281 

Path. 

PAGE 

No.  7276 500 

No.  7364 497 

No.  7448 72,74,75 

No.  7555 184 

No.  7800 157 

No.  7867 350 

No.  7895 528,531 

No.  7903 175 

No.  7925 24,25 

No.  7953 155 

No.  8116 133 

No.  8284  .  ,  ,15,128,133 

No.  8297 68,577 

No.  8325 645,646 

No.  8346 149 

No.  8347 280 

No.  8349 206 

No.  8350 232 

No.  8351 258 

No.  8370 190 

No.  8432 363,364 

No.  8445 88 

No.  8447 392 

No.  8458 204 

No.  8502 329 

No.  8579 440 

No.  8655 579 

No.  8714 336 

No.  8723 200,332 

No.  8727 306 

No.  8750 257 

No.  8776 49 

No.  8824 94,95 

No.  8825 135 

No.  8827 105,650 

No.  8829 260 

No.  8832 303 

No.  8838 108 

No.  8844 332 

No.  8887 260 

No.  8932 152,641 

No.  9129 259 

No.  9186 323 

No.  9233 103 

No.  9348 648 

No.  9349 491 

No.  9473 438 

No.  9502 270 

No.  9545 82 

No.  9546 270 

No.  9558 564 

No.  9642 133 

No.  9662 243 

No.  9755 336,384 

No.  9810 470 


rATHOLOGICAL    XIMJJKRS.  699 

PACJE                                                                                              PACK  PAGE 

Path.  No.  9840 649  Path.  No.  10311.  .  .  .97,99.239  Path.  No.  11191 339 

Path.  No.  10015.  .........  133  Path.  No.  10382 -)12  Path.  No.  11651 118 

Path.  No.  10033 271  Path.  No.  10417 474  Path.  No.  12090 310 

Path.  No.  10039 23  Path.  No.  10494 492.  493  Path.  No.  12618 28, 30 

Path.  No.  10076 73,  74  Path.  No.  10677 121   Path.  No.  12963 145 

Path.  No.  10077 263  Path.  No.  10776 487  Path.  No.  13121 139 

Path.  No.  10278 482  Path.  No.  11044 70  Path.  No.  13199 52 


AUTOPSY   NUMBERS. 


PAGE    I                                                                                           PAGE  PAGE 

Aut.  No.  23 395  Aut.  No.  610 395  Aut.  No.  1503 221,  685 

Aut.  No.  48 533  I  Aut.  No.  653 395, 396, 397  Aut.  No.  1593 395 

Aut.  No.  52 534  Aut.  No.  666 674  Aut.  No.  1605 414, 428 

Aut.  No.  55 674  Aut.  No.  680 395  Aut.  No.  1666 395 

Aut.  No.  69  .395,397,423,428  Aut.  No.  682 395  Aut.  No.  1689 442 

Aut.  No.  117 395,415,428  !  Aut.  No.  689 395,398,428  Aut.  No.  1703 395 

Aut.  No.  118 677  Aut.  No.  700 395  Aut.  No.  1734 674 

Aut.  No.  136 395,421,428  Aut.  No.  722 395  Aut.  No.  1745 397 

Aut.  No.  172 419,428  Aut.  No.  742 681  Aut.  No.  1754 395 

Aut.  No.  188 382,395,397  Aut.  No.  810 398,428  Aut.  No.  1809 683 

Aut.  No.  198 674  Aut.  No.  901 395  Aut.  No.  1823 395 

Aut.  No.  211 420,428  |  Aut.  No.  908. . .  .395,  396,  397,  Aut.  No.  1869 395 

Aut.  No.  237 674  [  678  Aut.  No.  1898 395, 428 

Aut.  No.  277  .  .  .395,  416,  428,  '  Aut.  No.  926 398, 428  Aut.  No.  1936 680 

540  Aut.  No.  954 390, 674  Aut.  No.  2080 395 

Aut.  No.  288 396,397  Aut.  No.  994 396,397  Aut.  No.  2088  .  .  .395,427,428 

Aut.  No.  322 395  Aut.  No.  1085  .  .  .  223,  395,  428  Aut.  No.  2162 674 

Aut.  No.  353 234  Aut.  No.  1112  .  .397,  422,  428,  Aut.  No.  2202 395 

Aut.  No.  385 674  583  Aut.  No.  2230 395 

Aut.  No.  474 395,428  j  Aut.  No.  1220 408,428  Aut.  No.  2293 681 

Aut.  No.  451 396,397  Aut.  No.  1310 395  Aut.  No.  2319 427,428 

Aut.  No.  505 405, 428  Aut.  No.  1337 395  Aut.  No.  2404 395 

Aut.  No.  519 395  Aut.  No.  1363 395  |  Aut.  No.  2426 395 

Aut.  No.  532 395  Aut.  No.  1371 428  '  Aut.  No.  2558 393 

Aut.  No.  561 674  ;  Aut.  No.  1387 678  Aut.  No.  2651 674 

Aut.  No.  579 395  Aut.  No.  1407 415,428  Aut.  No.  2671 417,428 

Aut.  No.  595 674  Aut.  No.  1445 6S0  Aut.  No.  2987 66 


701 


INDEX 


Abdominal    cavity,    bleeding    into,    after    bi- 
manual  examination   for  .subperitoneal 
pedunculated  myoma,  444 
irrigation    of,    after    abdominal    hystero- 

myomectomy,  620 
passage    of    enema    into,    after    hystero- 
myomectomy,  391 
Abdominal  contour  in  myoma  cases,  436 

hemorrhage,    symptoms     suggesting,     after 

abdominal  hysteromyomectomy,  669 
hysteromyomectomy,    588.     See    also    Hys- 
teromyomectomy, abdominal. 
metastases  with  myosarcoma,  200 
Abdominal  myomectomy,  506.     See  also  Myo- 
m,ectomy,  abdominal. 
operations  necessary  subsequent  to,  556 
pain  after,  549 
Abdominal  pregnancy,  myoma  and,  difTerenti- 
ation,  473-477 
veins,  enlargement  of,  437 
Abdominal  walls,   lipoma   of,  associated   with 
myoma,  461 
perforation  of,  by  myosarcoma  of  uterus, 

176 
thick,  rendering  hysteromyomectomy  diffi- 
cult, 630 
vessels    from,    supplying    nourishment    to 
parasitic  myoma,  51 
Abdominal     wound,     suppuration     of,     after 

hysteromyomectomy,  662 
Abscess   beneath   broad   ligament    in    myosar- 
coma of  utenis,  196 
between    intestines    and    omentum    due    to 

suppurating  myoma,  139 
burrowing  along  vagina,  196 
of  broatl  ligament  after  abdominal  myomec- 
tomy, 553 
with  myoma,  355 
of  kidney  with  uterine  myoiiiata,  397,  122 
of  lung  after  hysteromyomectomy,  682 
of  ovary  with  myoma,  344,  396,  637,  639 
omental,  with  uterine  myoma.  637 
on  .surface  of   uterus   due  to  perforation    ol 
suppurating  interstitial  myoma,  150 
Abscess,  pelvic,  anterior  to  myomatous  uterus. 
636 


Aljscess,  pelvic,  evacuation  of,  after  abdominal 
myomectomy,  559,  635 
myoma    a.ssociated    with,    aijdominal    liy- 

sterectomy  in,  635 
with  myomata  of  uterus,  635 
perirectal,  391 
pulmonary,    after    abdominal    hj-steromyo- 

mectomy,  669,  682 
tubo-ovarian,   a.ssociate(l  with  myoma,  344, 
396 
with  carcinoma  of  body  and  myoma,  290 
Abscesses,  multiple,  after  abdominal  hystero- 
myomectomy, 664 
Acces.sory  uterine  artery,  almost  fatal  bleeding 

from,  623 
Adenocarcinoma  of  ovary,  associated  with  my- 
oma, 348 
of  uterus,  associated  witli  myoma,  274,  275, 
276,  278 
early,  associated  with  myoma,  294,  295 

with  .suspicious  changes  in  myoma,  248 
extensive,  overlooked  at  operation.  286 
following  submucous  myoma,  248 
growing  into  myoma,  405 
inspection  of  cavity  for,  594 
myomectomy  in  case  of,  416 
rare  form  of,  489 

with    metasta.ses,    in    lym])h-glan(l.s     405, 
414 
in  left  adrenal  body.  108 
in  liver,  408 
in  lungs,  408 
in  mesentery,   lOS 
in  omentum,  105,  lO.S 
in  pancreas,  408 
in  peritoneiim,  105,   108 
in  pleura,   Kl.S 
in  s])le(Mi,   1 1  I 
Adcntx'arcinonia  of  utcius   with    tubo-ovarian 

abscess,  290 
Adenocystoma  of  o\ary   with  uterine  myoma, 

346,  39(),  117 
.\(_lenomyoma  of  round  liganicnts  w  itii  myoma, 
364 
of  uteio-ovarian  ligament   with  myoma,  360 
of  utcius,  167,  16S 


ro3 


704 


INDEX, 


Adeiiomyoma  of  uterus,  alxloiniual  niyoniec- 
tomy  for,  oil 
diffuse,  in  one  lioru  of  hiconiatc  uterus, 

157 
removal  of,  per  aI)tloineii,  .311 
witli  apparently  independent   round-celled 

sarcoma  of  uterus.  2S() 
with    double    cervix    and    (i()ul)Ie    vagina, 

155 
with  squamous-celled  carcinoma  of  cervix, 
262 
Adhesions,  appendiceal,  affording  hlood-supjily 
to  parasitic  myoma,  39 
between  liver  and  myoma,  464 
between  myoma  and  rectum,  386 
gradual     absorption     of,     after     abdominal 

hysteromyomectomy,  641 
in  myoma  cases,  found  at  autopsy,  395 
intestinal,  (')33 

after  abdominal  myomectomy,  566 
extensive,  method  of  dealing  with,  635 
of  bladder  in  myoma  cases,  role  played  by, 

3()(i 
ovarian,   release   of,   after   alidoniinal   myo- 
mectomy, 556 
to  broad  ligaments  in  myoma  cases,  354 
vesical,    release    of.    after   abdominal    myo- 
mectomy, n.'yC) 
Adipose  tissue  in  myoma,  162,  KiO 
Adrenal  body,  metastases  in.  from  adenocar- 
cinoma of  uterus,  40S 
Anastomosis,  uretero-ureteral.  383 

intestinal,  635 
Anesthesia  in  abddminai  liysteromyomectoniy, 

590 
Angiomyoma  of  uterus,  158 
Anus,  artificial,  with  complete  control,  190 
Appendicitis  a.ssociated  with  myoma.  463 
Appendix,     removal     of,     in     myoma     cases, 

463 
Areas,   raw.   with   abdoiiiiiiai   liysteromyomec- 

tomy,  619 
Artery,    uterine,    almost    fatal    bleeding    from 
accessory     branch,     during     abdominal 
hysteromyomectomy,  623 
fatal  hemorrhage  from,  due  to  absorption 

of  catgut,  681 
pa.ssage  of  silk  ligature  from,  into  bladder, 

375 
tearing    of.    during    abdominal    myomec- 
tomy, 525 
Ascites  associated  witii  myoma,  30 
Autopsy,    carcinoma   of   body   of  utenis   and 
myoma  found  at,  404 
of    cervix    with    uterine    myoma 
found  at,  398 


Autopsy   changes    found  in  ureter   associated 
with  myoma,  396 
condition    of    Fallopian    tubes    in    cases    of 
uterine  myoma,  395 
of  ovaries  in  myoma  cases,  395 
findings  in  myoma  cases,  394,  428 
myosarcoma  and  mj'oma  found  at,  420 
perforation  of  rectum  found  at ,  after  hystero- 
myomectomy, 390 

Ballottemext  with  uterine  myoma,  469 
Bastianelli,  Raffaele,  79 

Bed-sore  following  abdominal  hysteromyomec- 
tomy, 662 
abdominal  myomectomy,  55') 
Bicornate  uterus,  diffuse  adenomyoma  in  one 

horn  of,  157 
Bimanual     examination     of     a     subperitoneal 
pedunculated    myoma,    bleeding    into    ab- 
dominal cavity  after,  444 
Bisection  of  uterus,  608.     See  also  under  Hys- 
teromyomectomxj. 
dangers  of,  181,  609 
death  after,  683 

followed  by  intestinal  obstruction,  683 
for  submucous  myoma,  574 
Bladder,  adhesions  of,  after   abdominal  myo- 
mectomy, 556 
role  played  by,  in  myoma  cases,  366 
adventitious  vessels  furnished  by,  48 
ascent  of.  with  growth  of  myoma,  366 
blood  supply  from,  to  ])arasitic  myoma,  50 
calculus  in,  associated  with  uterine  myoma, 

375 
carcinoma  of,  .secondary  to  cervical  carcin- 
oma, 401 
displacement  of,  by  myoma,  365,  368 
full,  simulated  by  encysted  peritonitis,  371 
in  myoma  cases,  365-377 
inflammation  of.  after  alxlominal  myomec- 
tomy. 549 
in  myoma  cases,  377 
injurj^  of,  during  removal  of  uterine  myoma, 

371 
loss  of  control  of,  37() 

manipulation  of,  in  abdominal  hysteromyo- 
mectomy, 374 
passage  of  silk  ligatvire  from  uterine  artery 

into,  375 
pres.sure  on,  by  myoma,  365 
retention  of  urine,  376 
sacculation  of,  in  myoma  cases,  370 
sarcoma  of,  with  uterine  myoma,  420 
spontaneous  evacuation  of  broad  ligament 

abscess  into,  553 
symptoms  attributable  to  myoma,  376 


INDEX. 


roo 


Bladder    wall,  condition  of,  in   myoma   cases, 

370 
Bleeder,     constitvitioiial,     sncccssfui     liystero- 

niyomectomy  on,  625 
Bleeding.     See  Himorrhaqe. 
Bleeding;,     intermenstrual,    in     myoma    cases, 
444 
into  abdominal  cavity  on  bimanual  examina- 
tion of   subperitoneal    pedunculated    my- 
oma, 444 
Blood  in  uterine  cavity  in  myoma  ca.ses,  309 
Blood  .supply  of  myomata,  6 

of  parasitic  myoma,   16,  38,  39,  41,  48 
Blood-vessels  of  broad  ligament,  dilatation  of, 
with  myoma,  354 
of    uterine    mucosa,  alterations    in,   witii 
myoma,  317 
Bluish  color  of  vaginal  mucosa  with  myoma , 

439 
Breasts,  carcinoma  of,  associated  with  myoma, 
450 
colostrum  in,  with  uterine  myoma,  449 
condition  of,  with  uterine  myoma,  449 
in  differential  diagnosis  of  myoma  and  preg- 
nancy, 467 
tumors  of,  benign,  with  myoma,  450 
Broad   ligament,   abscess   beneath,   associated 
with  myosarcoma  of  uterus,  196 
abscess  in,  after  removal  of  myoma,  553 

associated  with  uterine  myoma,  355 
adhesions  to,  in  myoma  ca.ses,  354 
alterations    in,    as.sociated    with    uterine 

myoma,  354 
cyst  in,  396 
dilatation  of  blood-vessels  of,  witli  uterine 

myoma,  354 
dilated  lymph-spaces  in,  witli  myoma,  355 
hematoma  in,  during  alidominal  liystero- 

myomectomy,  623 
infection  of,  after  abdominal  liysteromyo- 

mectomy,  664 
myoma  of,  51,  53,  354,  510 

abdominal  myomectomy  for,  510 
secondary    nodule    in,    from    myo.sarcoma 

of  uterus,  195 
thickening  of,  witli  uterine  myoma,  1555 
I'niiicliial   lymph-glands,   metastases   in,    from 
adenocarcinoma  of  uterus,  405 
from  .squamous-cellcd   carcinoma  of  cei- 
vix,  .399 
Broiicliitis    after    alidDiiiiiial     liy^lciniiiyDiiK  <■- 
tomy,  ()()S 
myomectomy,  554 
Bronchopneumonia   after   aijdominal    hystero- 
myomectomy,  668,  685 
myomectomy,  '^iyo 
45 


C.\LC.\HEOu.s  nodules  in  me.sentery,  464 

plates  in  an  arterial  wall,  129 
Calcification  of  lieart   muscle  a.ssociated   with 
uterine  myoma,  424 
of  myoma,  126,  130,  132,  133,  268 
Calcium  salts,  how  deposited,  in  myoma,  127 
Calculus,  uterine,  with  myoma,  130 

vesical,  associated  with  myoma,  375 
Capillaries,   marked   proliferation   of  endothe- 
lium of,  in  myoma,  99 
Carcin(jma    of    body    of    uterus,  un.suspected 
during  abdominal  myomectomy,  540 
with  myoma,  detected  at  autop.sy,  404 
of  l:)reast,  a.ssociated  with  myoma,  450 
of  cervix,  associated  with  myoma,  262 
found  at  autopsy,  398 
early,  with  myoma,  269 
simulated  by  .submucous  myoma,  487 
suspicion  of,  with  myoma,  304 
with    primary    carcinoma    of    ovary    and 

myoma,  271 
with  sloughing  submucous  myoma,  398 
Carcinoma  of  P'allojiian  tube,  secondary,  witli 
myoma,  396 
of  omentum,  myoma  and.  differentiation.  499 
of  ovary,  primary,  with  carcinoma  of  cervi.x 
and  myoma,  271 
witli  myoma,  396 
with  carcinoma  of  stomach,  396 
of  rectum,  a.ssociated  with  uterine  myoma, 

391,  417 
of  uterus,  a.ssociated  with  myoma,  found  at 
autopsy,  404 
histological  changes  in  myoma  suggesting, 

491 
myoma  and,  differentiation,  485 
secondary,  witii  uterine  myoma,  295 
Cardiac    hyaline    ilegeneration,  witii    necrotic 
uterine  myoma,  423 
hypertrophy,  with  uterine  myoma,  414.  423 
lesions,     possil)ly     attributable     to    uterine 

myoma,  421 
.sounds  in  myoma  cases,  451 
Cardinal  vessels,  clamping  and  apjilicalion  of 

ligatures  later,  600 
Catgut,   dealli    following  use  of,   in   ai)tli>minal 
myomectomy,  541 
too  early  ab.sorption   of,   wilii    fatal    liemor 
rhage,  after  hysteromyomectomy,  681 
Cecum,  sujipurating  myoma  opening  into.  46 
Cells  in  myoiii;i.  9 

Cerebral     emliolus    following  abdominal   myo- 
mectomy, .")37 
Cervical  endomelrilis  with   myoma.  302 
glands,  dilatation  of,  with  myoma.  29S 
unfolding  of,  with  mvoma    302 


706 


INDEX. 


CerA'ical  lips,  edema  of,  with  myoma,  441 
lyniph-glands,    metastases   in     from   adeno- 
carcinoma of  body  of  utenis,  405 
Cervical  mucosa,  changes  in,  with  myoma,  297, 
302 
extensive  removal  of,  during  supravaginal 

hysteromyomectomy,  601 
polypi  of,  with  myoma .  29S,  300 
Cervical  myoma,  53 

abdominal  myonieotomy  for,  510 
associated  witii  atlenocarcinoma  of  uterus, 

278 
extensive,  hysterectomy  for,  ditiicult,  58 
large,  with  adenocarcinoma  of  body,  289 
removal  of,  through  abdomen,  510 
Cervical  stum]),  appearance   of,  after  abdom- 
inal hysteromyomectomy,  599 
hemorrliage    from  secondary   sarcoma  in, 

190 
return  of  myosarcoma  in.  17(),  190 
Cervix,  almost  obliterated,  witli  myoma,  441 
atrophj^  of,  associated  with  myoma.  78,  297 
carcinoma  of,  a.ssociatetl  with  myoma,  262, 
305,  398 
simulated  by  sul)nmcous  nwoma,  487 
with   myoma   and   primary   carcinoma   of 

ovarj^  271 
with  slovighing  subnuicous  myoma,  398 
Cervix,  closure  of,  after  hysteromyomectomy, 
596 
condition  of,  in  cases  of  myoma,  440 
double,   associated   witli   submucous  adeno- 

myoma,  155 
elongation  of,  with  myoma,  441 .  442 
hypertrophy  of,  with  myoma,  297,  441 
in  differential  diagnosis  of  myoma  and  preg- 
nancy. 467 
infection    of.    following   abdominal    hystero- 
myomectomy, 664 
involvement  of.  l)y  mycMua.  57 
jammed  down  on  jxTincum  in  myoma  cases, 

411 
normal,  with  myoma.  441 
pushed   u]i    Ix'liind    sym])liysis     in     myoma 

cases,  4  11 
return  of  .sarcoma  in.  212 
torsion  of,  77,  79 

transverse   .section   of,   as   preliminary   step 
in  abdominal  hysteromyomectomy,  612 
Ce.sarean  .section  with  death  four  years  after 

abdominal  myomectomy,  568 
Chills  with  submucous  uterine  myoma,  572 
Cholestorin  in  liroken  down  hyaline  material. 

125 
Chorda'  tendine:r,  metastases  in,  from  sarcoma 
of  uterus,  222 


Chorio-epithelioma      simulating      myomatous 

uterus,  482 
Cockscomb  sarcoma  on  surface  of  uterus,  184 
Colic,  renal,  with  myoma,  466 
Colon,  suppurating  subperitoneal  myoma  open- 
ing into,  142 
transverse,  descent  of,  with  myoma,  463 
Colostrum  in  breasts  with  myoma,  449 
ColunuKC  carneie  of -right  ventricle,  metastases 

in.  following  .sarcoma  of  uterus,  222 
Constipation  after  abflominal  hysteromyomec- 
tomy, 659 
with  uterine  myoma,  445 
Cornual  jiregnancy,  ruptured,  simulating  my- 
oma. 177 
Cor[Mis  liitcum  cysts  with  myoma.  346 
CuUen.  Ciiurcli  Home  ca.ses,  671 
Cystadenoma.    multilocular,    of    ovaries,   with 

myoma,  346,  396,  417 
Cystic   areas    containing    enndsified     fat,    92, 
124 
degeneration  of  myoma,  83,  92,  102,  111 
myoma,  112 

abdominal  myomectomy  for,  512 
character  of  fluid  in,  91 
resembling  heart  cavity,  122 
resembhng  ovarian  cy.st,  111 
Cj'stitis,  associated  with  myoma,  377 

following    abdominal    hysteromyomectomy, 

657 
following  myomectomy.  549 
Cysts,   corpus    luteum,   with   uterine   myoma, 
346 
dermoid,   of   ovaries,   with   uterine   myoma, 

349 
formation,  early,  in  myoma.  96 
Graafian  follicle,  with  uterine  myoma,  344 
in  myosarcoma,  197.  198 
labial,  with  uterine  myoma.  438 
large,  due  to  hyaline  degeneration  in  myoma, 

90 
of  ovary,  bilateral,  ami  myoma,  ilil'ferentia- 
tion,  498 
in  myoma  cases.  344 
myoma  and.  differentiation,  495 
papillo-cystomatous,  498 
removal   of,   during   abdominal    myomec- 
tomy, 527 
of  umbilicus  with  myoma,  462 
of  urachus  associated  with  myoma,  463 
of  utero-ovarian  ligaments  in  myoma  cases, 

356 
parovarian,  with  uterine  myoma,  353 
retention,  in  kidney,  with  myoma,  427 
tubo-ovarian,  with  myoma,  340 
vaginal,  with  mvoma,  439 


INDEX. 


ro- 


Death  after  abdominal  inyomcctoiny  probably 
due  to  infection  from  Falloj)ian  tubes,  541 
apparently     from     diarrhea     following     ab- 
dominal hysteromyomectomy,  681 
causes    of,    in    patients    succumbing    years 

after  abdominal  myomectomy,  570 
due  directly  to  myoma,  426,  427 
due  to  bronchopneumonia  after  bisection,  685 
due     to     peritonitis     following     abdominal 

hysteromyomectomy,  (573 
following    abdominal    hysteromyomectomy, 
672,  677,  678,  680,  681,  682,  684 
myomectomy,  532,  533,  538,  541,  543, 
544,  672 
bisection  of  uterus,  683 
Cesarean    section    four    years    after    ab- 
dominal myomectomy,  568 
uterine  hemorrhage,  399 
vaginal  myomectomy,  672 
Death  from  submucous  myoma,  no  operation 
performed,  584 
immediate,    following    abdominal    myomec- 
tomy, 532 
vaginal  myomectomy,  580 
myocarditis    probable    cause    of,    after    ab- 
dominal myomectomy,  544 
on  table,  543 

years  after  vaginal  myomectomy,  586 
Death-rate,  marked  reduction  in,  in  last  two 

years,  687 
Decidua  simulated  by  sarcoma,  218 
Defecation,  painful,  with  myoma,  446 
Degeneration,  cystic,  of  myoma,  83.     See  also 

Degeneration,  hyaline. 
Degeneration,  hyaline,  of  myoma,  8,  83-125, 

.395 
Delirium  aftei'  vaginal  myomectomy,  580 
Delusional  insanity  after  vaginal  hysteromyo- 
mectomy, 670 
Dermoid  cysts  of  ovaries  witli  myoma,  349 
Diagnosis  of  myoma,  467-503 
Discharge.     See  Vaginal  discharge. 
Discrete  myoma,  3 

Dislocation  of  ureters  witii  myoma,  378 
Displacement  of  bladder,  by  myoma,  365,  368 

of  rectum,  upward,  by  myoma,  386 
Diverticula,  ruptured,  rectal,  .")()() 
Double  ureter  with  myoma.  3Sl 
Drainage,   vaginal,   following   alxlomiiiMl    liys- 
toromvomcctomv,  (')23,  ()2  1 


Edkma  of  cervical  lips  witii  myoma,    111 
mucosa  with  myoma,  297 
of  legs  after  abdominal  liysteromyomectomy, 
658 


Edema   of   lower  extremities    associated   with 
myoma,  4.)0 

of  myoma,  88 

of  uterine  mucosa  with  myoma,  322 
Edematous  myoma,  giant-cells  in,  2.50 
Electrical  treatment  for  myoma,  588 
Embolism,    pulmonary,    fatal,    following    ab- 
dominal hysteromyomectomy,  680 
following  bisection,  684 
Embolus,  cerebral,  following  abdominal  myo- 
mectomy, ,")37 
Emulsification   of  hyaline   myomatous   tissue, 

92,  124 
Encysted    peritonitis    suggesting  full   bladder, 

with  myoma,  371 
Endocarditis,  acute  vegetative,  with  sloughing 
suVimucous  uterine  myoma,  422 

chronic,  with  myoma,  414 
Endocardium,  metastases  in,  froin  myosarcoma 

of  uterus,  220 
Endometritis,  cervical,  with  myoma,  302 

chronic,  associated  with  suppurating   inter- 
stitial myoma,  148 

with  myoma,  148,  302,  334 
Endometrium,  inflammation  of,  witli  myoma, 
334 

tuberculosis  of,  with  myoma,  335 
Epithelium     lining    uterine     cavity,     atypical 

changes  in,  with  myoma,  332 
Erysipelas    following    vaginal    operations    for 

myoma,  579 
Exophthalmic  goiter  associated  with  myoma, 

460 
Extra-uterine   pregnancy    and  myoma,  differ- 
entiation, 477 


Fai-LoI'Iax   tulx's.  adherent ,  with  myoma,  338 
affording  blood-supply  to  parasitic  myoma, 

38 
carcinoma  of,  .secondary,  396 
condition  of,  at  autopsy,  in  myoma  cases, 
395 

witli  myoma,  337 

with  myosarcoma  of  uterus,  177 
li('iii:iti»s:ilpin\.  witli  myom.-i,  ."viS.  ,39(1 
hydrosalpinx,  witli  myoma,  ;}.3S,  396 
infection   from   lluid    liberated    from,   5-11 
inflammation  of.  in  inyoma  cases,  338 
mc(li;ini(;il  .illcrations  in  relations  of,  with 

inynnia  cases.  '.\  \',\ 
niyonia  ol .  W  1 1 

nourishing  i)artially  parasitic  myoma,  38 
()])('rations    on,    during    abdominal    myo- 

mcctonn',  526 


ro8 


IXDKX. 


Fallopian  tubes,  pyosalpinx,  with  myoma.  396 

nulimciitary,  with  myoma,  340 

salpingitis,  with  myoma,  338 

tuberculosis  of,  with  myoma,  341,  396 

Family  history  in  cases  of  uterine  myoma,  430 

Fat,  emulsificil.  witli  cystic  areas,  in  myoma,  92, 

124 
Fecal    fistula,    temporary,    following    removal 

of  ruptured  suppurating  myoma,  142 
Femoral  hernia  associated  with  myoma,  462 
Fertility  in  cases  of  uterine  myoma,  457 
Fetus,  dead,  resembling  myomatous  uterus,  473 
death  of,  with  suppuration  and  jierforation 

of  uterine  wall,  470 
myoma  resembling,  in  contour,  4(59 
rescml)led  by  myoma,  (i 
Fever  with  submucous  uterine  myoma,  'u'2 
Fibroids  of  uterus,  1.     See  also  Myoma. 
recurrent,  178,  179,  252,  586 

operation  for,  after  vaginal  myomectomy. 
5X6 
Fibroma  of  ovary,  493 

and  myoma,  differentiation,  493-495 
with  myoma,  351 
of  uterus,  1.     See  also  Mijoma. 
Fibromyoma  of  uterus.  1.     vSee  also  Myoma. 
Fistula   in   ano   following  abdominal   hy.stero- 

myomectomy,  660 
Fluid  in  cystic  myoma,  91 

Flushes,  hot,  after  hysteromyomectomy,  603. 
604 

Gall-bladder,  adhesions  to,  with  myoma,  464 
Gangrene  of  ovary  after  hysteromyomectomy. 
222 

Gangrenous  .submucous  myoma,  66 

Giant  cells  in  suspicious  myoma,  250 

Glanfls.     See  Lymph-(flnntl.'<. 

(ilands, cervical, dilatation  of.  with  myoma,  298 

unfolding  of.  with  myoma,  302 

hypertrophy  of.  witli  myoma.  316.  325 
Glands,  running  parallel   to  .surface  of  uterine 

mucosa,  316 
unusual  shapes  of,  associated    with   uterine 

myoma,  321 
Glands,  uterine,  dilatation  of.  witli  myoma,  323 

hypertrophy  of,  with  myoma,  325 
Glycosuria  with  uterine  myoma,  465 
(loiter  with  uterine  myoma,  460 
(Iraafian  follicle  cysts  with  uterine  myoma,  344 
Gritty  particles  in  myoma,  126 

HALLrciNATlONS  following  abdominal  hystero- 
myomectomy, 661 
He;irt  (vivity,  cystic  myoma  resembling,  122 


Heart  complications  after  abdominal  hystero- 
myomectomy, 660 
hypertrophy  of,  with  necrotic  myoma,  423 
in  myoma  cases,  451 

lesions,  po.ssibly  attril>iit able  to  myoma,  421 
muscle,  calcification  of,  witii  myoma,  424 
hyaline    degeneration    of,    with    necrotic 

myoma,  423 
metasta.ses  in,  from  myosarcoma  of  uterus, 
176 
sounds  in  myoma  cases,  451 
Heart-shaped  myoma,  5 

Hematoma  tluring  abdominal  hysteromyomec- 
tomy, 623 
Hematosalpinx  with  myoma,  338,  396 
Hemoglobin  in  cases  of  myoma,  451,  4.")3,  455, 

517 
Hemorrliage,     abiloiiiiiial.     from     sarcoma     of 
cervical  stump.  190 
symptoms     .suggesting,     after     abdomina 
hysteromyomectomy,  669 
due  to  general  oozing  from  pelvis,  621 
due  to  slipping  of  ligature  during  abdominal 

hysteromyomectomy,  623 
during  abdominal  iiysteromyomectomy,  620, 

621,  622 
during  vaginal  myomectomy,  576 
rnliowing    abdominal    hysteromyomectomj-, 
654,  681 
abdominal  myomectomy,  548 
in  cases  of  .submucous  myoma,  572 
local  applications  as  means  of  checking,  588 
method  of  controlling,  where  needle  cannot 

be  employed,  620 
.secondary,  as  cause  of  death  after  abdominal 
hysteromyomectomy,  681 
Hemorrhoids  with  uterine  myoma,  446 
Heredity  as  cau.se  of  myoma,  430 
Hernia,  femoral,  with  myoma.  4()2 
inguinal,  witli  myoma.  462 
umbilical,  strangulated.  120 

with  carcinoma  of  cervix  and  myoma,  398 
with  myoma,  120,  461.  639 
Hernial    sac,     po.stoperative,     containing    my- 
omatous nodule,  4()3 
Histologic  appearance  of  e.iriy  iiiyoiiia.  431 

of  myosarcoma .  1 72 
Hot    fhi.shes  after  ai)dominal   hysteromyomec- 
tomy. 604 
Hot  weather  as  cau.se  of  poslopciativeelevation 

of  temperature,  655 
Hyaline  degeneration.  adNaiiced.    witii    liiiue- 
faction  and  formation  of  small  cysts,  88 
bright  yellow  areas  of,  87 
ca.ses  showing  various  types  of,  93 
giving  water-core  appearance,  95 


IXDKX. 


7()<) 


llyaliiu'    degeiiCM'atioii     in    muscle    l)Uiulle.s    of 
myoma,  85 
of  blood-vessel  walls  in  myoma,  86 
of  heart  muscle  with  necrotic  myoma,  423 
of  myoma,  8,  12,  83-125 

relation  to  sarcomatous  transformation. 

93,  232 
with  formation  of  larfje  cysts  in  myoma, 

90 
with    litjuefaction    and    cyst    formation. 
88,  89 
Hyaline  material  degenerated   and    containing 
cholesterin  crystals,  92,  124,  125 
tissue,  gradual  liquefaction  of,  103 
Hydatidiform     mole     resembling    myomatous 

uterus.  480 
Hydronephrosis  with  myoma.  397 
Hydrosalpinx  in  myoma  cases.  338.  396 
Hydroureter   with   uterine   myoma,   381,   396, 

399,  414 
Hypertrophy,  cardiac,  with  myoma,  414 
of  bladder  wall,  370 
of  cervical  mucosa  in  myoma  cases,  297 
of  cervix  in  myoma  cisss,  441 
of  round  ligaments  in  myoma  cases.  363 
of  uterine  glands  with  myoma,  316,  325 
of  uterus,  with  myoma,  11 
Hysterectomy  for    myoma.     See    HyHkromyu- 

mectomy. 
Hysterical  manifestations  following  abdominal 

myomectomy,  547 
Hy.steromyomectomy,  abdominal.  588,  626,  641 
accidental  ligation  of  ureter  during.  382 
acute  mania  after,  661 
adenocarcinoma  of  body  of  uterus  over- 
looked at.  2S(i 
after  abdominal  myomectomy,  559 

on     account     of     development     of 
otlier  myoma.  561 
after-treatment,  627 
almost      fatal     bleeding     from     acces.sory 

braucli  of  uterine  artery  in.  623 
anesthetic  in,  590 

appearance  of  cervic.i!  stiinip  after,  599 
bed-sore  after,  662 
bisection  of  uterus  in.  608,  683,  684,  685. 

See  also  Bisection  of  uterus. 
bronchitis  after.  ()()8 
liniiiclinpneiiiiionia  aftei'.  668 
cardiac  complications  after,  6()() 
clam])ing  of  cardinal  ves.selsand  applicat  Idii 

of  ligatures.  600 
closure  of  cervix  in.  596 
complicatiiins  fullnwiim,  65  1.  (iliS 
constipation  aftei-.  (i59 
cystitis  after.  657 


Hysteromyomectomy,  alxloniinal,  dark-brown 

vomit  us  after,  658 
death   after,  causes  of,  672,  673,  681,  682, 

683,  684,  685 
difficult,  58,  630 
edema  of  legs  after,  658 
employment  of  round  ligaments  in  suspen- 
sion of  cervical  stump  in,  603 
extensive     removal    of     cervical    mucosa 

during.  601 
fistula  in  :uio  after,  660 
from  below  upward,  612 
gangrene  of   ovary   and.    222 
gradual  ab.sorption  of  adliesions  after.  641 
hallucinations  after.  661 
heart  complications  after.  660 
hematoma  during.  623 
hemorrhage  after.  654,  681 

during.  620-623 

local  applications  as  means  of  check- 
ing, 588 
hot  flushes  after.  603 
immediate  removal  of  appendages  in.  607 

results  from,  672 
in  apparently  inoperable  myoma  case,  636 
in  constitutional  bleeder,  625 
in  intestinal  adhesions,  633 
in  kidney  diseases,  625 
in  myoma  adherent  to  abdominal  wall,  630 

associated  with  pelvic  ai)scess,  635 

filling  pelvis,  631 
in  syphilis,  625 
indications  for,  590 
infection  of  cervix  after,  664 
injury  of  bladder  during.  371,  374 

to  rectum  during.  387 

to  ureter  during,  382 
inspection  of  uterine  cavity  for  cancer  and 

myoma  for  .sarcoma  in.  591 
intestinal  obstruction  after.  6.')!t,  677 

worms  after.  659 
irrigation  of  ai)dominal  ca\ily  after.  620 
left   to  riglit .  w  itii  I'cniowd  nf  appen(|ages. 

location  ol'  ureters  during.  385 
nudliple  abscesses  after.  664 
myocarditis  as  cau.se  of  dcaili  .ifii-r.  6S2 
nausea  after,  (').')>< 
ncplirccl  oiiiy  .'iftci',  .'{SI.  HS.') 
iiei)lirilis  after.  657 
nerxous  phenonicna  .ifter.  661 
ol)stipati()n  after,  659 
operatixc  com|)lications.  (530 
partial  su|)])ression  of  urine  after.  657 
passage   of  enema    into   aixiominal   ca\ily 
after.  391 


710 


INDEX. 


Hystcromyomectomy,  abdominal,  pelvic  infec- 
tion after,  G()2,  003,  004 
involving  broad  ligament  or  Douglas' 

sac  after,  004 
limited  to  cervix  after,  004 
perforation  of  rectum  after,  390 
on  account  of  adhesions   after   abdominal 

myomectomy,  559 
peritonitis  as  cause  of  death  after,  073 
phlebitis  after,  005,  007 
pleurisy  after,  007 
pneumonia  after,  009 
preliminary  treatment.  020 
present  health  after.  005 
preservation  of  ovaries  in.  594.  003 
pulmonary  abscess  after,  ()09,  082 

embolism  as  cause  of  deatli  after,  OSO 
pulse  after,  650 
raw  areas  after,  019 
rectal  tears  in,  387 

tenesmus  after,  059 
removal    of      tulx-rculous     kidney    after. 

384 
resection  of  sigmoid  flexure  during,  389 
results,  072 
right  to  left,  with  removal  of  appendages, 

600 
secondary  hcinorrliage  as  cause  of  death 

after,  081 
shock  as  cause  of  death  after,  078 
silk   ligature    from   uterine  artery   passed 

into  bladder  after,  375 
subsequent    to    abdominal    myomectomy, 
559 

vaginal  myomectomy,  585 
suppuration  of    abdominal   wound    after. 

662 
tearing  of  ovarian  vessels  during,  621 
temperature  after.  655 
thrombosis  of  ovarian  veins  and,  222 
transverse  section  of  cervix  in,  012 
tying  cardinal  vessels  and  removing  uterus 

in,  595 
urine,  partial  suppression  after,  057 

retention  after,  657 
vaginal  drainage  after,  623 
vermicular  contraction  of  ureters  during. 

385 
vicarious  menstruation  after.  ()05 
vomiting  after,  058 
when  abdominal  walls  are  thick,  630 
when  pelvic  abscess  exists,  035 
Hysteromyomectomy,    supravaginal,    for   my- 
oma, 593 
myosarcoma  overlooked  during,  190 
vaginal,  629 


Hystei'omyomectomy,    vaginal,    compHcat  i<jns 
after,  070 

delusional  insanity  after,  070 

results  after,  085 

transitory  lack  of  recognition  after,  670 
Hysterotomy,  509,  510 


Iliac  veins,  compression  of,  by  tumor,  234 
Incarcerated  myoma,  305 
Incontinence  of  urine  with  myoma  cases,  370 
Indviration  of  vaginal  vault  with  myoma,  440 
Inflammation  of  bladder  after  abdominal  myo- 
mectomy, 549 
with  myoma,  377 
of  cervical  mucosa  in  mj'oma  cases,  302 
of  endometrium  in  myoma  cases,  334 
of  Fallopian  tubes  in  myoma  cases,  338 
Inguinal  glands,  metastases  in,  from  squamous- 
celled  carcinoma  of  cervix,  399 
hernia  associated  with  myoma,  402,  403 
lymi)li-glantls,    carcinoma   of,   secondary   to 
adenocarcinoma  of  body  of  uterus,  405 
Insanity  following  vaginal  hysterectomy,  070 
Intermenstrual  bleeding  with  myoma,  444 
Interstitial  myoma,  1 

abdominal  myomectomy  for,  508,  521 
invaded  by  squamous-celled  carcinoma  of 

cervix,  403 
suppurating,  144 

results  after  operation  for,  153 
Interstitial  myosarcoma  of  uterus,  171 

pregnancy  simulating  myomatous  uterus,  477 
Intestinal  adhesions,  550,  033,  035 

abdominal  hysteromyomectomy  and,  033 
Intestinal  obstruction  after  abdominal  hystero- 
myomectomy, 659,  677 
myomectomy,  533,  552,  566 
after   bisection    of   uterus   for   myoma 
683 
years  after  jdxlominal  myomectomj',  557 
vessels  furnishing  nourishment  to  myoma,  41 
worms  following  abdominal  hysteromyomec- 
tomy, 659 
Intestine,   sarcoma    of,    secondarj-    to    uterine 
sarcoma,  234 
small,  nourishing  parasitic  myoma,  47 
ovarian  abscess  opening  into,  639 
suppurating  myoma  opening  into,  47 
Intraligamentary  myoma,  1,   187 
suppurating,  137 
upward  pressure  of,  305 
Intraligamentary  myosarcoma  of  uterus,  171 
Inversion  of  uterus  with  submucous  myoma,  71 
Irrigation  of  abdominal  cavity  after  hystero- 
Tiivomectomv,  020 


INDEX. 


11 


Johns  Hopkins  Hospital  autopsy  records,  39-4 
cases,  671 


Kelly  sanitarium  cases,  671 
Kidney,  changes  in,  at  autopsy,  in  myoma  cases, 
397 
complications  following;  abdominal  hystero- 

myomectomy,  657 
dilatation  of  pelvis  of,  with  myoma.  397 
diseases  of,  alidominal  hysteromyomectomy 

in,  625 
miliary  abscesses  of,  with  myoma,  397,  422 
misplaced,  Avitli  myoma,  465 
nodules  in,  with  myoma,  465 
removal  of,  subsequent  to  injury  of  ureter, 

383 
retention  cysts  in,  427 

tuberculous,  removal   of,  after  hysteromyo- 
mectomy, 384 
Kidney-shaped  myoma,  4 


Labial  cyst  with  myoma,  438 

Lateral  anastomosis  where  extensive  intestinal 

adhesions  exist,  635 
Left  to  right  abdominal  hysteromyomectomy, 

606 
Legs,  edema  of,  with   myoma,    450;  after  ab- 
dominal hysteromyomectomy,  658 
Leukocytosis    following    abdominal    myomec- 
tomy, 553 
in  myoma  cases,  152 
Leukorrhea  with  submucous  myoma,  571 
Ligament,  broad,  abscass  in,  after  abdominal 
myomectomy,  553 
adhesions  to,  with  myoma,  354 
alterations  in,  associated  with  myoma,  354 
dilatation  of  vessels  of,  with  myoma,  354 
dilated  lymph-spaces  in,  with  myoma,  355 
hematoma  in,  during  abdominal  hystero- 
myomectomy, 623 
myoma  of,  354,  510 
sarcoma  in,  secondary  to  myosarcoma  of 

uterus,  195 
thickening  of,  witli  myoma,  355 
used  to  cover  over  myomectomy  incision, 
525 
Ligaments,  round,  adenomyoma  of.  in   myoma 
cases,  364 
alterations  in,  witli  myoiiia,  3(')1 ,  3('2 
employment  of,  in  sus])ension  of  cervical 
stump    in    abdominal    hysteromyomec- 
tomy, 598,  603 
hypertrophy  of,  witii  myoma,  363 
myoma  of,  363 


Ligaments,  utero-ovarian,  adenomj'oma  of,  in 
myoma  cases,  360 
changes  in,  with  myoma,  356 
cysts  of,  with  myoma,  356 
myoma  of,  358 

secondary     sarcomatous  nodules  in,  with 
myoma,  360 
Ligation  of  ureters,  accidental,  during  hystero- 
myomectomy, 382 
Ligature,  passage  of,  from  cervical  stump  into 
bladder,  375 
slipping  of,  with  hemorrhage,  during  abdom- 
inal hysteromyomectomy,  623 
Lipoma    of    abdominal    wall    associated    witli 

myoma,  461 
Lipomyoma  of  uterus,  162 
Lips,  cervical,  edema  of,  with  myoma.  441 
Liquefaction  of  hyaline   myoma,   88,  89,    103, 

104 
Liver,  and  myoma,  adhesions  between,  464 
condition  of,  with  myoma,  464 
metastases     in,    from     adenocarcinoma     of 
uterus,  408 
myosarcoma  of  uterus,  176,  201 
sarcoma  of,  secondary  to  sarcoma  of  uterus, 

234 
thickening  of,  associated  with  myoma,  464 
Lobar  pneumonia  after  abdominal  hysteromyo- 
mectomy, 669 
myomectomy,  555 
Lumbar  glands,  metastases  in,  from  sarcoma 

of  uterus,  222 
Lungs,    abscess    of,    and     bronchopneumonia, 
after  hysteromyomectomy,  682 
metastases     in,     from     adenocarcinoma     of 
uterus,  408 
from  myo.sarcoma  of  uterus,  176.  195,  220, 

234 
from  s(iuamous-ce]lcd  carcinoma  of  cervix. 
399 
septic    infarction    of,    with    sloughing    suli- 
mucous  myoma,  422 
Lym]>iiatic  activity  in  jiarasitic  myoma,  14 
Lymphatics,  omental,  dilatation  of,  14,  20,  22 
uterine,  dilatation  of,  associated  with  myoma, 
72,  7C) 
Lymiili-ciiaiuu'ls,  (iiiatccl.  in  myoma  cases,  123 
Lymph-glands,  l)roncliiai,  metastases   in,   from 
adenocarcinoma  of  uterus,  405 
from     sciuamoiis-ccllcd     carcinoma      of 
cervix.  3i)9 
cervical,    metastases    in,   from    ailenocarciii- 
oma  of  uterus,  405 
I  ruin  myo.sarcoma  of  uterus,  195 
inguinal,     metasta.ses     in,  from  adenocarci- 
noma of  body  of  uterus,  405 


712 


INDEX. 


Lyiiipli-gUinds,   iiifiuiiuil,   metastases   in,  from       Metastases    from   sarcoma  of   uterus    to    peri- 


squamous-celled      carfinoma     of      cervix, 
399 

lumbar,    metastases    in.    from     sarcoma    of 
uterus,  222 

mediastinal,  metastases  in,  fiom  ailenocarcin- 
oma  of  uterus,  414 

mesenteric,  metastases  in,  from  squamous- 
celled  carcinoma  of  cervix,  399 
sarcoma    of,    secondary     to    sarcoma    of 
uterus,  234 

])('lvic,  metastases  in.  from  s(iuamou.s-celled 
carcinoma  of  cervix,  399 

pericardial,     metastases     in.     from     adeno- 
carcinoma of  uterus,  40') 

pcripancreatic,  sarcoma  of,  234 
Lymph-spaces,  (jilatcd.  in    hioad    liiranient.  in 

myoma,  3.").') 


.Malkokmatiox.s  of  uterus,  myoma  associated 

with.  1,55,  157 
Mania,    acute,    after    alxiominal    hysteromyo- 

niectomy.  G()l 
.Mediastinal  lymph-glands,  meta.sta.ses  in,  from 

adenocarcinoma  of  uterus,  414 
Menstrual     flow,     retained,     enlargement     of 
uterus  due  to,  485 
history  in  myoma  cases,  443 
.Menstrual  inn      in      differential      diagnosis      of 
myoma  and  pregnancy.  4(J7 
influence  of  myoma  on,  443 
vicarious,      after     altdoininal      liysteromyo- 
mectomy.  f)()5 
Mesenteric  lymph-glanils,. sarcoma  of,  secondary 
to  sarcoma  of  uterus,  234 
vessels   affording   blood-sup))iy   to    parasitic 
myoma.  39 
Me.senterj%  ahnDnu.dly  long,  in   myoma   cases, 
4G4 
calcareous  nodules  in,  witli  myoma.  4(54 
metastases     in.     from     adi-nocarcinoma     of 
utenis.   lOS 
from  .-(luamous-cellcd  carcinoma  of  cervix. 
399 
.sarcoma  of,  secondary  to  sarcoma  of  uterus. 
234 


pancreatic  lymph-glands,  234 
in    adrenal    body   from    adenocarcinoma    of 

utenis,  4()S 
in  broncliial    lynii)li-glands  from  s^iuamous- 

celled  carcinoma  of  cervi.x,  399 
in   inguinal   lymph-glands    from    s(iuamou.s- 

celled  carcinoma  of  cervix,  399 
in  intestine,  secondary  to  sarcoma  of  uterus, 

234 
in  liver  from  adenocarcinoma  of  uterus,  234, 

408 
in  lumbar  glands  from  .sarcoma  of  uterus,  222 
in   lungs   from  adenocarcinoma   of  body  of 
uterus,  408 

from  sf|Uamous-c('lic(l  carcinoma  of  cervix 
399 

.secondary  to  sarcoma  of  uterus,  195,  234 
in   mediastinal    lymph-glands   from    adeno- 
carcinoma of  uterus.  414 
in  mesenteric  lymph-glands,  from  squamous- 
celled  carcinoma  of  cervix,  399 
seconflary  to  sarcoma  of  uterus,  234 
in  mesentery,  from  adenocarcinoma  of  uterus, 
408 

.secondary  to  sarcoma  of  uterus.  234 
in  omentum,  499 

from  adenocarcinoma  of  uterus,  408 

secondary  to  sarcoma  of  uterus,  234 
in  pancreas,  from  adenocarcinoma  of  uterus, 

408 
in     peritoneum,     from     adenocarcinoma    of 
uterus,  408 

from  s(:[uamous-celled  carcinoma  of  cervix, 
399 

secondary  to  sarcoma  of  uterus.  195,  234 
in   pleura,  from   adenocarcinoma  of    uterus, 
408, 414 

from  squamous-celled  carcinoma  of  cervix, 
399 

secondary  to  sarcoma  of  uterus.  234 
in  spleen,   from   adcnocai'cinoma  of  body  of 

uterus.  41  t 
in  stomach,  secondary  to  sarconui  of  uterus, 

234 
of  chorda;  tendineae  of  tricuspid  valve  follow- 
ing sarcoma  of  uterus.  222 


Metastases,    alxiominal.    with    myo.sarcoma   of       Miscarriages  in  myoma  cas3s,  458 


uterus.  200 


Mobility  of  myomata,  444 


from  adenocarcinoma  of  uterus  to  bronchial  importance  of  determining,  before  opera- 


lymph-glands,  405 
to  cervical  lymph-glands,  405 
to  inguinal  lymph-glands,  405 
to  omentum,  405 
to  pericardial  lymph-glands.  405 
to  peritoneum,  405 


tion,  445 
Mole,    hydatid,    myoma    and.    dificrentiation, 

480 
Mortality.     See  Dcdih. 
Mucosa,  cervical,  changes  in,  in  myoma  cases, 

297,  298,  302 


INDEX. 


13 


Mucosa,  cervical,  extensive  removal  of,  during 

supravaginal  hysteromyomectomy,  601 
Mucosa,   uterine,    blood-vessels  of,  alterations 
in.   in   myoma  casss,  317 
condition  of,  with  myoma,   '297.  310,  310, 
317,  322,  334 
in  myosarcoma  of  uterus,  17G 
small  myoma  developing  in,  333 
thrombosis  of  veins  in,  with  myoma,  320 
unusual  gland  shapes  in,  associated  with 
myoma,  321 
Mucosa,    vaginal,    bluish    color  of.    in    myoma 

cases,  439 
Mulberry-shaped  myoma,  1,  2,  .5 
Multilocular  cystadenoma  of   ovary  with  niy- 

oma,  346,  396,  417 
Muscle  bundles,  hyaline  degeneration  in,  85 
extension  of,  into  uterine  muco,sa,  317 
heart,  ca,lcification  of.  with  myoma,  424 
uterine,   and   myoma,   line   of   junction   be- 
tween. S 
condition  of,  with  myoma,  11 
myoma  extending  into,  9 
Myocarditis  as  probable  cause  of  death  after  nb- 
dominal  hysteromyomectomy, 682 
myomectomy,  544 
Myoglia  in  myoma,  9 
Myoma,  1 

abdominal  contour  in,  436 

hysterectomy  for,  588.     See  also  Hystero- 
myomectomy, abdominal. 
myomectomy    for,    506.     8ee    also  Myo- 
mectomy.  abdominal. 
abdominal    pregnancy     and,   differentiation. 

473 
abdominal  veins,  enlargement  of,  with,  437 
abnormally  long  mesentery  with,  464 
abscess  of  broad  ligaments  witli,  355 
of  omentum  with,  637 
of  ovary  witli,  344.  39(5,  637,  639 
adenocarcinoma  of  ovary  and,  34S 

of  uterus  a.ssociated  witii,  271.     See  also 
Adenocarcinoma  of  uterus. 
adenocystomata    of   ovary    with,    346,    396, 

117 
adenomyoiiiM    nl    round   ligameut.s  witli,  3()4 

of  utero-ovaiiaii  ligament  with,  360 
adherent   F;illi)pian  tubes  with.  33S 

ti)    ali(l()inin;il    \\;ill,    .-il idnniiiml    hysterec- 
tomy foi-.  (■):',() 
adhesions  wit  li.  found  at   autopsy,  395 
of  bladder  in,  role  ])layed  liy,  3()6 
to  broad  lig.aments  \\ith,35l 
to  ir.'dl  liliiddcr  with.    161 

to  ii\cr  with,  n; I 

to  rcctiirii  with    .3X6 


Myoma,  advanced  hyaline  degeneration  of,  with 

liquefaction     and      formation     of     small 

cysts,  88 
age  of  incidence  of,  434 
alveolar  appearance  of,  due  to  proliferation 

of  endothelium  of  blood  capillaries,  99 
apparently  inoperable,  abdominal  hysterec- 
tomy for,  636 
appendicitis  as.sociated  with,  4()3 
areas  of  adipose  tissue  in,  162,  166 
a.scites  associated  with,  30 
autop.sy  findings  in  ca.ses  of,  394,  397,  428 
ballot tement  with,  469 
bilateral  ovarian  cysts  and,   difTerentiation, 

498 
bisection  of  uterus  for,  608 
bladder  and.  365,  370,  377 
blood  in  uterine  cavity  with,  309 
blood-supply  of.  6 

bluLsh  color  of  vaginal  mucosa  with.  439 
breasts  in  cases  of,  449,  450 
calcareous  nodules  in  mesentery  in.  464 

plates  in  walls  of  artery  in.  129 
calcification  of,  126,  268 
carcinoma  extending  into.  405 

of  brea.st  a.s.sociated  with,  450 

of  cervix  a.ssociated  with,  262,  398 

of  Fallopian  tube  with,  396 

of  ovary  with,  396 

of  rectum  with,  391,  417 

of  stomach  and  oxarv  with.  396 

of  uterus  with,  404,  485 

a.ssociated  with,  cases  of,  274 
cardiac  hypertrophy  with,    11  1 
cau.se  of,  430 
cells  of.  9 

changes  in,  .suggesting  .sarcoma.  238,  242, 
243 

transition    into    sarcoma    cells.     188,   225, 
226.  227.  228 
Myoma,  cervical,  .")3 

abdominal  myomectomy  for.  510 

adenocarcinoma  of  uterus  ami.  27*<. 

endometritis  with.  302 

poly|(i  with.  29S 
(•(■r\i\  .-ilniost  obliterated  with.    111 

januucd  down  on  perineum  with. 
\\\)  Ix'hind  symphysis  with.    111 
choiio-epithelioma  and.    IS2 
chronic  endocarditis  with,   11  1 
cleavage  from  utei'ine  muscle  with.  8 
clinical  course  of.  431 
clinically  o\'ershadow  ing  adenocarcinoma  of 

uterus.  275 
colostiMini  of  breasts  wit  h.    1  19 
constipation  associ.ated  with,   145 


2S9 


1  11 


714 


INDEX. 


Myoma,  corpus  luteum  cysts  with,  346 
cystic,  abdominal  myomectomy  for,  512 
cystic  degeneration  of,  S3.    See  also  Hyaline 

degeneration. 
cystitis  witli,  877 
cysts  of  ovary  witli,  344 

of  uraclms  with,  403 

of  utero-ovarian  ligaments  with,  356 
dead  fetus  resembling,  473 
death  due  directly  to,  426 
degeneration  in,  found  at  autopsy,  395 
dermoid  cyst  with,  349,  396 
diagnosis  of,  differential,  467-503 
dilatation  of  cervical  glands  with,  298 

of  deeji  uterine  lympliatics  associatetl  with, 
76 

of  renal  pelvis  with,  397 

of    superficial    uterine    lymphatics    asso- 
ciated witli.  72 

of  ureters  witli,  378 

of  uterine  glands  with,  323 

of  vessels  of  broad  ligaments  with,  354 
dilated  lymph-channels  in,  123 

lymph-spaces  in  broad  ligament  with,  355 
dis:i])pearance  of,  after  jiregnancy,  646 
discrete,  3 

duration  of,  before  operation,  435 
edema  of,  88 

effect  of  removal  of  ovaries  on,  5U4 
electrical  treatment  of,  588 
elongation  of  sujiravaginal  ]^ortion  of  cer\ix 
with,  442 

of  vaginal  portion  of  cervix  with,  441 
enudsification  of  hyaline  material  in,  92,  124 
encysted  peritonitis  suggesting  a  full  bladder 

witli,  371 
endometritis  with,  334 
extending  into  uterine  muscle,  9 
extra-uterine  pregnancy  and,  477 
Fallopian  tubes  and,  338,  340 
family  history  and,  430 
femortd  hernia  a.ssociated  with,  462 
fertility  and,  457 
fibroma  of  ovary  and,  351,  493 
free  in  broad  ligament,  51,  187 
gall-bladder  with,  464 
giant  cells  in,  250 

gland  hypertropliy  of  mucosa  with,  316,325 
glands,  unusual   shapes  of,  associated  with. 
321 

running    parallel    to    surface    of    uterine 
mucosa  with,  316 
glycosuria  with,  465 
goiter  with,  460 
Graafian  follicle  cysts  with,  344 
gritty  particles  in,  126 


Myoma,  heart  in  cases  of,  421,  451 
heart-shaped,  5 
hematosalpinx  with,  338,  396 
hemoglobin  percentage  with,  451,  453,  455, 

517 
hemorrhoids  associated  with,  446 
heredity  and,  430 
histologic  appearances  of,  7 

changes  in,  suggesting  carcinoma,  491 
hyaline     degeneration    of,     83.      See     also 

Hyaline  degeneration. 
hydatid  mole  and,  480 
hydronephrosis  with,  397 
hydrosalpinx  with,  338,  396 
hydroureter  with,  381,  396.  399,  414 
hypertrophy  of  bladder  wall  with,  370 

of  cervical  mucosa  with,  297 

of  cervix  uteri  wuth,  441 

of  round  ligaments  with,  363 

of  uterine  glands  with,  325 
hysterectomy  for.     See  Hysteromyomectomy. 
in  contour  resembling  a  fetus,  469 
in  old  age,  395 
incarcerated,  365 
incontinence  of  urine  with,  376 
induration  of  vaginal  vault  with,  440 
inguinal  hernia  associated  with,  462 
inoperable,  treatment  of,  636 
Myoma,  interstitial,  1 

abdominal  myomectomy  for,  508 
intestinal  obstruction  associated  with,  447 
intraligamentary,  1,  365 
irregvdar  growth  of,  10 
kidney,  miliary  abscesses  in,  complicating,397 

misplaced,  with,  465 

nodules  in,  a.ssociated  with,  465 
kidney-shaped,  4 
labial  cyst  with,  438 
large  ovary  with,  352 
leukocytosis  with,  152 
lipoma  of  abdominal    wall  with,  461 
li([uefaction  of,  88,  89 
liver  and,  464 

loss  of  weight  with,  456,  572 
macroscopic  appearances  of,  1 
malformation  of  uterus  with,  155 
menstrual  history  in  cases  of,  443 
merging  of,  into  an  ovary,  353 
mesentery,  findings  in,  associated  with,'^464 
microscopic  appearances  of,  early,  431 
miscarriages  with,  458 
mobility  of,  444 
nndberry-shaped,  1,  2,  5 
nndticystic,  112 
myoglia  in,  9 
nausea  associated  with,  447 


INDEX, 


15 


Myoma,  necrotic,  153 

with  cardiac  hypertrophy,  423 

with  hyaline  degeneration  of  heart  muscle, 
423 

with  pyonephrosis,  423 
Myoma,  number  of,  3 

removetl  by  abdominal  myomectomy,  .')17 
obliteration  of  cervix  with,  441 

of  umbilical  depression  with,  461 
of  broad  hgament,  51,  53,  354,  510 

abdominal  myomectomy  for,  510 
of  Fallopian  tubes,  341 
of  round  ligaments  of  uterus,  363 
of  utero-ovarian  ligaments,  358 
omental  carcinoma  and.  499 
origin  of,  433 

ovarian  cysts  and,  344,  495 
pain  with,  448,  449 
painful  defecation  associated  with,  446 

urination  with,  376 
panhysterectomy  for,  593,  616 
papillocystoma    of    ovaries    and    adenocar- 
cinoma of  uterus  with,  408 

of  ovary  with,  346 
Myoma,    parasitic,    13.       See    also     Parasitic 

myoma. 
parovarian  cysts  with,  353 
pear-shaped,  4 
pedunculated,  1,  2 
pelvic  abscess  with,  635,  636 

molds  and,  6 

peritonitis  with  abscess  formation  and,  344 
perirectal  absce.ss  with,  391 
phleboliths  in  vaginal  wall  with,  440 
polypi  of  cervical  mucosa  with,  298 

of  uterus  associated  with,  325,  328,  329 
pregnancy  and,  467,  473,  477,  507,  643 
pres.sure  of,  on  bladder,  365 

on  iliac  veins,  234 

on  ureters,  381 

pains  with,  44S 
prolap.se  of  rectum  with,  391 

of  uterus  with,  460 
pruritus  ani  associated  with,  446 

vulva?  with,  444 
pyelonephrosis  with,  397 
pyometra  as.sociated  with,  310 
pyo.salpinx  with,  338,  340,  396 
rectal  diverticula,  rupture  of,  and,  .')()() 
rectum  and,  386 
removal  of,  in   apimrcnlly  iiiopcraljic    cases, 

636 
renal  colic  with.    Kid 
reseml)lanc('  of.  to  Ictus,  (5 
respiration  and,  4.')() 
results  of  operations  for,  671 


Myoma,  retention  cj-sts  in  kidney  with,  427 

of  urine  witii,  376 
retraction  of  umbilicus  with,  461 
retroperitoneal,  development  of,  631 

sarcoma  anrl,  501 
sacculation  of  bladder  with,  370 
sacral  markings  with,  5 
saddle-liag  appearance  of  uterus  with,  5 
salpingitis  with,  338 

sarcoma  developing  from,  169,  172,  173,  ISO, 
208,  420 

of  bladder  a.ssociated  with,  420 

of  uterus  and,  492 
secondary  carcinoma  of  uterus  with,  295 
Myoma,  sessile,  1,  2 
shape  of,  4 
simulated  by  chorio-epithelioma,  482 

by  extra-uterine  pregnancy,  477 

by  hydatidiform  mole,  480 

by  omental  metastases,  499 

by  retained  menstrual  flow,  485 

by  retroperitoneal  sarcoma,  501 

by  simple  ovarian  cysts,  497 
size  of,  3 
small   developing  in  uterine  mucosa,  333 

unattached  to  uterus  and  situated  between 
tube  and  ovary,  364 
snugly    filling   pelvis,    rendering   abdominal 

hysteromyomectomy  difficult,  631 
sterility  associated  with,  457 
Myoma,  submucous,  1,  59,  571.     See  also  Sufi- 

mucoiis  myoma. 
Myoma,  subperitoneal,  1,  45,  81,  134,  249,  444, 

508 
Myoma,  subvesical,  365,  510 
Myoma,  suppurating,  134-153 

cause  of,  152 

interstitial,  144 

intraligamentary,  137 

opening  into  cecum,  45 
into  colon,  142 
into  small  bowel,  47 

subperitoneal,  134,  135.  139 
conununicating  with  bowel,  134 
su.spicion  of  carcinoma  of  cervix  with.  302, 

304 
.symjitoms  of,  434-4.')9 
t('m])erature  with,  457 
tliickening  of  broad  ligaments  with,  '.^bo 

of  left  lobe  of  liver  with,  464 
t  hi((-i('af-clover-.'<haped,  5 
tiirill  felt  on  vaginal  exann'nation  with,  442 
thrombosis  of  veins  in  muco.sa  with,  320 
torsion  of  ccrxix  with.  77 

of  uterus  witli.  77.  79 
t  I'.-msitioii  of,  into  sarroiiia,  1S2 


716 


IXDKX. 


Myoma,  transverse  colon,  descent  of,  with,  463 
troiitmont  of,  504,  506,  571,   58.S,   629,   630, 

(171 
tubal  i)regiianoy  with,  342 
tuberculosis  of  endoinetriuiu  with,  335 

of  Fallopian  tubes  with,  341,  396 

of  uterus  associated  witli,  421 
tuberculous  jieritonitis  associated  with,  464 
tubo-ovarian  abscess  witli.  290,  344,  396 

cysts  with,  340 
ulceration  of  vagina  with,  440 
umbilical  cyst  as.sociated  witii,  462 

licrnia  associated  witli.  461,  (539 
umbilicus  and,  461 
uiifohUnii  of  cervical  ylands  with,  302 
unrecognized    sarcomatous  degeneration  in, 

193 
ureters  in  cases  of.  37S-3S5 
urination  and.  376 
uterine  cavity  and,  305 

polypi  associated  with.  325 

.stones  in,  130 
vagina,  size  of,  with,  439 

vaginal,  associatecl  with  uterine  myoma,  234, 
440 

cy.sts  with,  439 

hysterectomy  for,  ()29. 
hysterom  yomectom ;/ . 

myoma  a.ssociated  witl 

myomectomy    for,   571.     See    also    Myo- 
mectomy, vagindl. 

stones  in,  440 
Myoma,  varieties  of.  1 

vein  stones  in  vagina  witii,  440 
vesical  adiiesions  with,  366 

calculus  witli.  375 
vomiting  as.sociated  with,  447 
weakness  with,  457 
weight  of,  119.  512 
Myomatous  tendency,  4 
Mj'omectomy,  abdominal,  .")06 

abscess  in  broad  ligament  after,  553 

age  of  patients  in  cases  of,  .506,  518 

and  hysterectomy  on  account  of  develo])- 
ment  of  other  myomata.  561 

bed-sores  after,  'in'y 

bronchitis  after,  554 

bronchopneumonia  after,  555 

carcinoma  of  uterus  not  disco\-ored  during, 
lUi 

cystitis  after,  549 

death  after,  532,  533,  537,  538,  540.  541. 
543,  544,  568 

(hiring  pregnancy,  528,  529,  538 

evacuation  of  pelvic  abscess  after,  559 

for  adcMioinvoma  of  uterus.  511 


See  also   Vaginal 


440 
See 


Myomectomy,  abdominal,  for  cervical  myoma, 

510 
for  cystic  myoma.  512 
for  interstitial  myoma,  508,  521 
for  niyonia  of  iiroad  ligament,  510 
for  petlunculated  myoma,  521 
for  submucous  myoma,  509,  523 
for    subperitoneal    pedunculated    myoma, 

508 
for  sub  vesical  myoma.  510 
for     suppurating     subperitoneal     myoma, 

fecal  fistula  after.  142 
foul  discharge  from  uteru.'^  after.  5.50 
hemoglobin, low, as  contraindication  to.  517 
hemorrhage  after,  548 
hysterectomy  after,  559,  560 
hysterical  manifestations  after,  .547 

results  after,  568,  569,  570,  672 
in  syphilitic  patient,  518 
intestinal  adhesions  after,   .566 

ob.struction  after,  533,  .5.V2,  557 
leukocytosis  after,  553 
lobar  pneumonia  after,  555 
location  of  myoma  and.  .")07 
myocartlitis  with,  544 
nau.sea  after,  548 
nephritis  after,  550 
number  of  myomata  removed  by,  517 
operations  on  tubes  and  ovaries  during,  526 

performed  in  conjunction  with.  526 

subsequent  to,  556,  570 
pain  after,  549 
peritonitis  after,  .")33,  552 
phlebitis  after,  '>')') 
pleurisy  after.  5.54 

postoperative  complications  and.  54  4 
pregnancy  following.  566 
preservation  of  portion  of  fundus  in.  525 
pul.se  after,  .545,  546 
pus  from  urethra  after,  550 
release  of  adhesions  after,  5.56 
removal  of  ovarian  cysts  during,  527 

of  ovaries  after,  5.58 

of  tvil)es  or  ovaries  during,  .326 

of  \ermiforin  ;ippendix  and,  463,  557,  5.58 
repair  of  perineum  duiing,  527 
repeated,  5.38 

size  of  myomata  removed,  5!  1 
sloughing  of  uterine  wall  after,  551 
suspension  of  uterus  during,  .328 
.■syphilis  as  contraindication  to,  518 
tearing  of  uterine  artery  during,  .325 
teclinic  of,  .321,  523 
temperature  after,  545,  546 
tonsillitis  after,  5.34 
vomiting  after,  548 


IXDKX, 


T 


Myomectomy,  vaginal,  571,  .")77 
bisection  of  myoma  in,  HH 
complications  after,  578 

during,  576 
death  after,  580-583,  586 
delirium  after,  580 
erysipelas  after,  579 
for  infect etl  and  disintegrating  submucous 

myoma,  575 
for  non-infected  submucous  myoma,  573 
hemorrhage  during,  576 
hysterectomy  subsequent  to,  585 
operation  for  recurrent  fibroids  after,  586 
operations  subsequent  to,  585 
other  operations  during,  578 
phlebitis  after,  579 
pregnancy  after,  587 
pulse  after,  578 

results  after,  584,  586,  587,  672 
rupture  of  uterus  during,  576 
temperature  after,  578,  579 
Myosarcoma  of  uterus,  169-261 

abscess  in  broad  ligament  with,  196 

age  of  incidence,  178 

cervical  stump,  return  in,  176,  190 

clinical  history,  177-179 

condition  of  Fallopian  tulies  witli,  177 

of  ovaries  with,  177 

of  viterine  mucosa  with,  176,  190 
cysts  in,  197,  198 

developing     from     comiective     tissue     of 
myoma,  172 

from  degenerated  myoma,  188 

from  muscular  elements  of  myoma,  173 

in  center  of  myoma,  208 
gross  appearances  of,  170 

suggesting,  236-245 
histologic  appearances,  172 
incidence  of,  suggesting,  245-261 
Myosarcoma  of  uterus,  interstitial,  171 
Myosarcoma  of  uterus,  intraliganientary,  171 
metastases  in  abdomen  from,  200 

in  cervical  lymph-glands  from,  195 

in   chordir   tendinea'  of  tricuspid   \alvc 
fnini,  222 

in    colunuKi'    carncu'    uf    right    Ncntricjc 
from,  222 

in  cndocanlium  from,  220 

ill  iii'art   iniisclc  IVoin,  171) 

in  liver  from,  17(1,  201 

in  limgs  rioin.  17(1.  1'.).".,  •_'_'() 

in  lyni])h-glands  fidiii.   17(1 

ill  (iinciitum  fnim,  17(1 

in  |ili'iir;i   IVoni,   195 

ill  skill  frnin,  17(1 

in  \'ert('br;r  iVdin,  17(1 


Myosarcoma  of    uterus,  o^•(■rl()()ked  at  opera- 
tion, 190 
in  laboratory,  193,  2(J{).  204 
perforation  of  abdominal  wall  with.  176 
rapidity  in  growth  of,  176 
recurrence  of,  17(1 
relation  of  hyaline  degeneration  to,  232 

of  recurrent  fibroids  to,  178 
secondary  growths  of,  175 

nodules  of ,  in  right  broad  ligament,  195 
Myosarcoma  of  uterus,  submucous,  171 
Myosarcoma  of  uteru<,  subperitoneal,  171 

transition  of  muscle  fibers    into  sarcoma 

cells  in,  225,  226,  227,  228 
treatment  of,  179 


Nausea  after  abdominal  hysfcromyomectomy. 
658 
myomectomy,  548 
associated  with  myoma,  447 
Necrotic  myoma,  153 
Nephrectomy  after  hysteromytjmectomy,  384, 

385 
Nephritis    after    abdominal    hysteromyomec- 
tomy,  657,  681 
myomectomy,  550 
Nervous  phenomena  after  abdominal  hystero- 

myomectomy,  661 
Number  of  myomata,  3 


OnsTiPATioN      after     abdominal     hystcromyo- 

mectomy,  659 
Omental  adhesions  with  iiai'asitic  inyonia,  15 
carcinoma,  myoma  and,  differentiation,  499 
metastases,  499 

from  adenocarcinoma  of  iitcrns,  405,   108 
from  myosarcoma  of  uterus,  176 
vessels,  friability  of,  16 
Omentum,  abscess  in,  with  myoma.  637 

affording  part  of  blood-sujiply   to   parasitic 

myoma,  16-30 
(•h:inges  in,  witli  parasitic  myoma.  13 
dilated  lymphatics  of,   I  I.  20,  22 
gradual     disappearance     of     fat      in,     with 

parasitic  myoma,  22,  23,  25,  2S 
greatly    dilated    vessels    of,    with    jiarasitic 

myoma,  24 
secondary  sarcoma  of,  234 
Ovarian  adhesions,  rt4eas('  of,  after  abdominal 
myomectomy,  556 
cysts,  myoma    and,  different  iat  ion.    195,498 
lia|iilloinatous,    I9S 

reiiioxal    of,    during    alidoiniiial    iiiyoinec- 
tomv,  527 


718 


INDEX. 


Ovarian  cysts,  simple,  resembling  myoma,  497 
simulated  by  myoma,  111,  119,  495 

veins,    thrombosed,    after   hysteromyomec- 
tomy,  222 

vessels,  tearing  of,  during  aljdoininal  hystero- 
myomec'tomy,  621 
Ovary,  abscess  of ,  witli  myoma,  344,  637,  390, 
639 

adenocarcinoma  of,  with  myoma,  348 

adenocystoma  of,  with  uterine   myoma,  346, 
396,  417 

alterations  in  Inctition  of,  with  myoma,  352 

carcinoma  of,  carcinoma  of  cervix  with,  271 
of  stomach  with,  396 
primary,  with  myoma,  396 

condition  of,  witii  myoma,  337,  343,  395 
with  mj-osarcoma  of  uterus,  177 

corpvis  luteum  cyst  of.  with  myoma,  346 

cysts  of,  with  myoma,  344 

dermoid  cyst  of,  349,  396 

effect  of  removal  of,  on  myoma,  504,  505 

fibroma  of,  351,  493 

gangrene  of,  following  hysteromyomectomy, 
222 

Graafian  follicle  cysts  of,  with  myoma,  344 

largo,  with  myoma,  352 

merging  of  myoma  into,  353 

muitilocular  cystadcnoma  of,  witii  myoma, 
346,396,  417 

operations  on,   ilurinu    alxloininal    myomec- 
tomy, 526 

papillf)cystoma  of,  346,  408,  498 

preservation  of,  in  abdominal  hysteromyo- 
mectomy, 594,  603 

removal  of,  after  abdominal   myomectomj', 
558 
during  aljdoniiiKil  niyoni(>ctomy,  526 


Pa IX,  al^dominal,  after  myomectomy,  549 

with  myoma,  376,  446,  448 
Pancreas,  metastases  in,  from  adenocarcinoma 

of  uterus,  408 
Panhysterectomy  for  myoma,  593,  616 

for  suspected  myosarcoma,  ISO 
Papillocystoma  of  ovary  with  myoma,  346 

with     myoma     and    adenocarcinoma     of 
uterus,  408 
Parasitic  myoma,  13 

abdominal    walls    affording    blood-supply 

to,  51 
ascites  associated  with,  30,  31,  497 
l)ladder  affording  blood-supply  to,  48, 49,  50 
etiology  of,  14 

extruded   from   uterus  ami   lying   free   in 
broad  ligament,  39,  51 


Parasitic    myoma,    Fallopian    tubes    affording 
blood-supply  to,  38 
free  from  uterus,  29,  39 
intestinal   vessels   affording   l)lood-supply 

to,  41 
lymphatic  activity  in,  14 
mesenteric   vessels,   peritoneum,   and   ap- 
pendiceal   adhesions    affording    blood- 
supply  to,  39 
omental  adhesions  with,  15 
omental  changes  with,  13 
omentum  affording    part  of   blood-supply 

to,  10-30 
opening  into  bowel,  47 
into  cecum,  45 
Parovarian  cysts  with  mj'oma,  353 
Parovariutn,  alterations  in,  with  myoma,  355 
Pear-shaped  myoma,  4 
Pedunculated  myoma,  1,  2,  521 

subperitoneal,     abdominal     myomectomy 
for,  508 
submucous  myoma,  59,  61 
suppurating  subperitoneal  myoma,  139 
Pelvic  abscess,  anterior  to  myoma,  636 

evacuation  of,  after  abdominal  myomec- 
tomy. 559 
myoma  associated  with,  635 
floor,    hemorrhage   from   vessels   of,   during 

abdominal  hysteromyomectomy,  622 
infection  after  abdominal  hysteromyomec- 
tomy, 662,  663,  664 
Pelvic  lymph-glands,  metastases  in,  from  scjua- 
mous-celled  carcinoma  of  cervix,  399 
molds  and  myoma,  0 

peritonitis    after    abdominal    myomectomy, 
552 
with  abscess  formation  in   myoma  cases, 
344 
Pelvis,  myoma  filling,  abdominal  liysterectomy 
for,  031 
of  kidney,  dilatation  of.  with  myoma,  397 
Pericardial  lymph-glands,  metastases   in,  from 

adenocarcinoma  of  uterus,  405 
Pericardium,  metastases  in,  from  myosarcoma 

of  uterus,  170 
Perineum,  repair  of,  during   alidominal    myo- 
mectomy, 527 
Peripancreatic    lymph-glands,    .secondary   sar- 
coma of,  234 
Perirectal  abscess  with  myoma,  391 
Peritoneal  cavity,  large  suppurating  interstitial 

myoma  opeiung  into,  151 
Peritoneum    affording    l)lood-supply    to    para- 
sitic myoma,  39 
carcinoma  of,  secondtiry  to  adenocarcinoma 
of  uterus,  405 


INDEX. 


719 


Peritoneum,  metastases  in,   from  adenocarcin- 
oma of  uterus,  408 
from  squanaous-celled  carcinoma  of  cervix, 
399 
secondary  sarcoma  of,  23-4 
Peritonitis  as  cause  of  death  after  abdominal 
hysteromyomectomy,  G73-G7() 
myomectomy,  533 
bisection  of  uterus  for  myoma,  G83 
encysted,    suggesting    a    full    bkulder    with 
myoma,  371 
Peritonitis,  pelvic,   after  abdominal  myomec- 
tomy, 552 
with  abscess  formation,  with  myoma,  344 
tuberculous,  associated  with  myoma,  464 
Phlebitis  after  abdominal  hysteromyomectomy, 
665,  666,  667 
myomectomy,  555 
vaginal  myomectomy,  579 
Phleboliths  in  vaginal  wall  with  myoma,  440 
Pleura,  metastases  in,  from  adenocarcinoma  of 
uterus,  408,  414 
from  squamous-celled  carcinoma  of  cervix, 
399 
probable  metastases  in,  from  myosarcoma  of 
uterus,  195,  234 
Pleurisy,    acute,    with    sloughing    submucous 
myoma,  422 
after  abdominal  hysteromyomectomy,  667 
myomectomy,  554 
Pneumonia  after  abdominal   hysteromyomec- 
tomy, 669,  682 
myomectomy,  555 
Polypi  of  cervical  mucosa  with  myoma,  298 

uterine,  associated  with  myoma,  325,  328,  329 
Pregnancy,  abdominal,  myoma  antl,  differen- 
tiation, 473-477 
myomectomy  during,  528,  529,  530,  531, 
538 
after  abdominal  myomectomy,  566-568 
after  vaginal  myomectomy,  587 
changes  in  myoma  due  to,  645 
complicated  l»y  large  cervical  myoma,  532 
Pregnancy,  cornual,   ruptvu'e  of,   myoma  and, 
differentiation,  477 
disai)])earance  of  myoma  after,  MV> 
extra-uterine,  niy(ini;i  and.differcntiat  ion,  177 
fatal  abdominal  myomectomy  in  case  of,  .')3S 
interstitial,  rupture  of,  myoma   and,  477 
myoma  and,  459,  467,  507,  643,  648 
ruptured   cornual  or  interstitial,   simulating 

myoma,  477 
tubal,  and  myoma,  342 
Pressure  on  ureters  by  myomata,  381 
pains  with  myoma.  448 
symptoms  with  snlnnncons  niyoniii,  572 


Prolajjse  of  rectum  \\itli  myoma,  391 

of  uterus  associated  with  myoma,  460 
Pruritus  ani  associated  with  myoma,  446 

vulvae  associated  with  myoma,  444 
Pulmonary  abscess  after  abdominal   hystero- 
myomectomy, 669,  682 
embolism  as  cause  of  death  after  abdominal 
hysteromyomectomy,  680,  684 
Pulse   after   abdominal    hysteromyomectomy, 
656 
myomectomy,  545,  546 
vaginal  myomectomy,  578 
Pus,  escape  of,  from  urethra,  after  abdominal 
myomectomy,  550 
in  uterine  cavity  with  myoma,  310 
Pyelonephrosis  with  myoma,  397 
Pyometra  associated  with  myoma,  310 
Pyonephrosis  with  necrotic  myoma,  423 
Pyosalpinx  associated  with  myoma,  338,  340, 
396 


Raw     areas,     covering    of,     after    abdominal 

hysteromyomectomy,  619 
Rectal   diverticula,    rupture   of,    myoma   antl, 
500 
tears,  387 

tenesmus  after  abdominal  hysteromyomec- 
tomy, 659 
Rectum  and  myoma,  adhesions  between,  386 
carcinoma  of,  associated  with  myoma,  417 
displacement  of,  upward,  by  myoma,  386 
injury  to,  during  hysteromyomectomy,  387, 

390 
perforation     of,     after     hysterectomy     for 

myoma,  390 
))rolapse  of,  with  myoma,  391 
Recurrent  fibroids,  178,  179,  252,  586 
relation  of,  to  myosarcoma,  178 
Renal  colic  with  myoma,  466 
insufficiency,  451 

lesions,    abdominal    hysteromyomectomy    in 
patients  suffering  from,  ()25 
Resection  of  sigmoid  flexure  and   removal   of 

myoma,  389 
Respiration,  ei'fect  of  myoma  on,   l.'iO 
Retention  cysts  in  kidney,   127 

of    urine    after    abdominal    hysteromyomec- 
tomy, 657 
with  myoma,  .376 
Hetraelion  of  uinbiliens  with  myoma.   Kil 
Retroi)eritoneal  development   of  myoma,  631 

sarcoma,  myoma  and,  dilferent  iation,  .")01 
I^ound  ligaments,  atieiiomyoma  of,  3()4 
altered  relations  of,  361 
as  tense  b;inds  with  myoma,  362 


720 


ixnKX. 


Rdund  ligaments,  changes  in,  with  myoma,  '.HM 
hypertrophy  of,  with  myoma,  363 
inserted  in  cervical  stump,  596,  603 
lengthening  of,  with  myoma,  36"2 
myoma  of,  363 
Rudimentary  Fallopian  tube  witli  myoma,  340 
Rupture   of   rectal    diverticula,    myoma    and, 
differentiation,  500 
of  uterus  during  vaginal   myomectomy,  576 

Sachai,  markings  on  myoma,  5 

Saddle-bag  appearance  of  uterus  with  myoma,  5 

Salpingitis  with  myoma,  338 

Salts,  calcium,  deposit  of,  in  myoma,  127 

Sarcoma  and  myoma,  169-261 

colony  development  of  cells  in,  21  1 
developing  from  (•()rui('cti\('  tissue  of  myoma, 

172,  173 
inspecting  myonui  for,  tluring  operation,  594 
of  bladder  associated  with  myoma,  420 
of    cervical    stinni),    al)d()niinal    lunnorrhage 

from,  190 
of  liver  secondary  from  uterus,  234 
of     omentum     sccoiulary     to     sarcoma     of 
uterus,  234 
Sarcoma  of  uterus,  169,  492 

metastases  from,  222,  234,  iiOO 
myoma  and,  492 
resembling  myoma,  21(i 
relation  of  hyaline  degeneration  to,  93 
resembling  decidua,  218 

retroperitoneal,     myoma     and,     differentia- 
tion, .501 
return  of,  in  cerxix,  190,212 
suggested  by  cell   changes   in    myoma,   242, 

243,  245 
unusual,  on  surface  of  uterus,  184 
with  fading  of  myoma,  217 
Sarcomatous  change  in  myoma,  169,  420.     See 

also  Mjfo.stnToniti  oj  ufcrufi. 
Sausage-shapi'd  sloughing  sul)mucous  myoma, 

70 
Sessile  myoma,  1 ,  2 
Shapes  of  myomata,  4 

Shock    as    cause    of    death    after    alKloininal 
hysteromyomectomy,  678 
bisection  of  uterus  for  myoma,  684 
Sigmoiil   flexure,  careinoina    of,   with  myoma, 
389,391 
furnishing  ves.scls  to  myoma,  44 
hematoma  of,  during  abdominal  hystero- 
myomectomy, 623 
resection  of,  and  removal  of  myoma,  389 
Skin  metastases  from  myosarcoma  of  uterus,  176 
Slipping  of  ligature   with   hemorrhage   during 
abilominal  hysteromyomectomy,  623 


Sloughing    of    uterine    wall    after    abdominal 

myomectomy,  .551 
Slougliing  submucous  myoma,  63,  64,  67,  68,  70, 

398 
Spleen,  metastases  in,  from  adenocarcinoma  of 

uterus,  414 
Squamous-celled  careinoina  of  cervix,  invading 
myoma,  403 
metastas(>s  from,  399,  401 
with  adenomyoma  of  uterus,  262 
with  fatal  hemorrhage,  399 
with  myoma,  2f)2 
Stercoraceous  vomiting    after  al)tlominal  hy.s- 
teromyomectomy,  658 
myomectomy,  548 
Sterility    associated    with    adenocarcinoma    of 
uterus,  274 
with  myoma,  457 
Stomach,    carcinoma    of,    with    carcinoma    of 
ovary,  396 
sarcoma  of,  secondary  to  sarcoma  of  uterus, 
234 
Stones,  uterine,  with  myoma,  130 
Strangulated  umbilical  hernia,  120 

inguinal  hernia  associated  with  myonui,  463 
Sul^nucous  myoma,  1,  59,  571 

abdominal  myomectomy  for,  509 

technic  of,  523 
age  of  incideTice,  571 
death  without  operation  in,  584 
fever  and  chills  with,  572 
gangrenous,  66 
hemorrhage  from.  572 
hysterotomy  for,  510 

infected  and  disintegrating,  vaginal  myo- 
mectomy for,  575 
inversion  of  uterus  associated  with.  71 
leukorrhea  with,  571 
loss  of  weight  with,  .572 
myomectomy    for,    571.      See    also    Mi/o- 

DKctomy,  raginol. 
pedimculated,  59,  61 
pressure  symptoms  from,  572 
removal  of,  509,  523 
siimdating  carcinoma  of  cervix,  487 
size  of,  .59 
sloughing,  f)3 

abscesses,  miliary,  in    left    kidney  with, 

422 
carcinoma  of  cervix  with,  398 
causing  toxemia,  427 
histologic  appearances  of,  68 
lung,  septic  infarction  of,  cnniplieating, 

422 
odor  from,  t)7 
pleuri-sy  with,  422 


INDEX. 


721 


Submucous  myoma,  sloughing,  sausage-shaped, 
70 
size  of,  64 

vaginal  discharge  from,  (17 
vegetative  endocarditis  witli,  422 
suspicious  changes  in,  248,  281 
symptoms  of,  571 
thrombi  of  vessels  with,  ()7 
vaginal  discharge  with,  571 
Submucous  myosarcoma  of  uterus,  171 
Subperitoneal  myoma,  1,  185-144 
edema  in,  249 

hemorrhage  from  jjcdicle  of,  621 
suppurating,  134,  l.':i9 

adherent  to  abdominal  wall,  1.36 
communicating  with  bowel,  134 
torsion  of,  81 
Subperitoneal  myosarcoma  of  uterus,  171 
pedunculated     myoma,      abdominal     myo- 
mectomy for,  508 
bleeding    into    abdominal    cavity    after 
bimanual  examination  of,  444 
Subvesical  myoma,  365,  510 
Suppression  of  urine  after  hysteroniyomectomy, 

657,  682 
Suppurating  interstitial  myoma,  144,  146-152 
results  after  operation  for,  153 
with  perforation  of  uterus,  150 
intra-ligamentary  myoma,  137 
Suppurating  myoma,  134-154 
cause  of,  152 
opening  into  cecum,  45 
into  small  bowel,  47 
results  after  operation  for,  153 
symptoms  of,  152 
treatment  of,  153 
subperitoneal  myoma,  134-144 

adherent  to  abdominal  wall,  136 
communicating  with  bowel,  134 
pedunculated,  139 
results  after  operation,  153 
rupture  of,  139 
Suppuration  of  abdominal  wound  after  abdom- 
inal hysteroniyomectomy,  ()62 
of  uterine  wall  after  death  of  fetus,  170 
Supravaginal  hysterectomy  for  inyoma,  593> 
portion  of  cervix,  elongat  ion  nf,  with  inyoinn, 
442 
Suspension    of    uterus    iil'lcr    alulniiiin.Ml    inyn- 

mectomy,  525,  528 
Syphilis, abdominal  hysteroniyoinccloiny  in,  625 
as     contraindication     to     al>d(iininal     niyn- 
mectomy,  518 

TiOAUS  into  I'cctal  lunicri   duiing   iiystcroniyo- 
mectomy,  387 
46 


Temperature  after  abdominal  hysteromyomcc- 
tomy,  655 
after  abdominal  myomectomy,  545,  546 
after  vaginal  myomectomy,  578,  579 
in  myoma  cases,  457 

Tenesmus,    rectal,    after    abdominal    hystero- 
niyomectomy, 659 

Three-leaf-clover-shaped  myoma,  5 

Thrill  felt    on  vaginal   examination   witli   my- 
oma, 442 

Thrombosed  ovarian  veins  after  hysteroniyo- 
mectomy, 222 

Thrombosis  of  blood-vessels  in  sloughing  sub- 
mucous myoma,  67 
of  veins  in  uterine  mucosa  with  myoma,  320 

Tonsillitis  after  abdominal  myomectomy,  554 

Torsion  of  cervix  uteri  with  myoma,  77 
of  subperitoneal  myoma,  81 
of  uterus  with  myoma,  77,  79 

Toxemia  from  sloughing  submucous  myoma,  427 

Treatment  of  myoma,  504,  506,  571,  588,  629, 
630,  654,  671 

Tubal  pregnancy  with  myoma,  342 

Tuberculosis  of  endometrium  with  myoma,  335 
of  Fallopian  tubes  with  myoma,  341,  396 
of  uterus  associated  with  myoma,  421 

Tuberculous  kidney,  removal  of,  after  hystero- 
myomectomy,  384,  385 
peritonitis  associated  with  myoma,  464 

Tubo-ovarian  abscess  with  myoma,  344 

and  adenocarcinoma  of  uterus,  290 
cysts  with  myoma,  340 

Tumors  of  breast,  benign,  with  myoma,  450 


Ulceration  of  vagina  with  myoma,  440 
Umbilical  cyst  associatinl  with  myoma,  462 
depression,  obliteration    of,  associated  with 

myoma,  461 
hernia,  strangulated,  120 

with  carcinoma  of  cervix  ami  myoma,  398 
with  myoma,  461,  639 
rml)ilicus,  condition  of,  with  myoma,  461 
rrachus,  cysts  of.  associated  with  myoma,  4()3 
I'l'eter,   accidental   cutting  of,   iluiinu    iiystero- 
iiiyDUiectoiuy,  'AS'.i 
and  niynuKi,  378-385 
cDiidit  ion  of,  in  myoma  cases,  396 
(hlatatioii  t)l,  in  myoma  cases,  378 
dislocation  of,  in  myoma  cases,  378 
(loul)le,  in  myoma  cases,  381 
injury  to,  during  hysteroniy<iniect(iniy,  382, 
:;.s:;,  3si 

ligation   of,   accidental,   during   hysteroniyo- 

niectoiiiy.  3S2 
loc.'it  ioii  of,  <luring  liysteroniyoiiiectoniy,  385 


722 


INDEX. 


Ureter,  position  of,  in  myoma  cases,  378 
pressure  on,  by  myoma,  381 
vermicular  contraction  of,  385 
rretero-ureteral  anastomosis,  with  subsequent 

removal  of  kidney,  383 
Urethra,  escape  of  pus  from,  after  abdominal 

myomectomy,  550 
Urination  in  myoma  cases,  370 
Urine,  retention  of,   after  abdominal  hystero- 
myomectomy,  657 
suppression    of,    after    alxlominal    hystero- 
myomectomy,  ()57,  682 
Uterine  artery',  bleeding  from  accessory  branch 
of,   during  abdominal    hysteromyomec- 
tomy,  623 
fatal    hemorrhage    from,    due    to    catgut 

absorption,  681 
passage  of  silk  ligature  from,  into  bladder, 

375 
tearing    of,    dm-iiig    abdominal     myomec- 
tomy. 525 
Uterine  cavity,  blood  in,  in  myoma  cases,  309 
epithelium    lining,    atypical    changes    in, 

in  myoma  cases,  332 
obliteration  of,  partial,  in  myoma  cases,  308 
opening  of  suppui-ating  interstitial  myoma 

info,  1  K; 
pus  in,  in  inyonia  cases,  .310 
size  and  shape  of,  in  myoma  cases,  305 
Uterine  discharge,  character  of,  in  myoma,  442 
foul,    following   al)dotniii;d    myomectomy, 
550 
glands    associated     witli     myoma,     unusual 
shapes  of,  321 
dilatation  of,  323 
hypertrophy  of,  325 

running    parallel    to    surface    of     uterine 
mucosa,  316 
iiorii,  diffuse  adcnoniyoma  of,   in  liicornate 
uterus,  l.')7 
dilatation  of  lympliatics  of,  74 
lymphatics,     dilatation    of,    associated    with 
myoma,  72,  76 
Uterine    mucosa,  blood-vessels  of,  alterations 
in,  in  myoma  cases,  317 
condition  of,  in  myoma  cases,  297,  310 

in  myosarcoma  of  uterus,  176 
edema  of,  in  myoma  cases,  322 
extension  of  nuiscle  info,  in  myoma  cases, 

317 
glands  running  parallel  to  surface  of,  in 

myoma  cases,  316 
small  myoma  developing  in,  333 
thrombosis  of  veins  in,   with   myoma,  320 
unusual    gland    shapes    associated    with 
myoma  in,  321 


Uterine  muscle  and    mj-oma,   line  of  junction 
between,  8,  9,  10 
condition  of,  with  myoma,  11 
Uterine   polypi   associated  with   myoma,  325, 

328,  329 
Uterine  stones  with  myoma,  130 
Uterine     vessels,     hemorrhage     from,    during 

abdominal  hysteromyomectomy,  621 
U  teiine    wall,  perforation   of,  after  death  of 
fetus,  470 
.sloughing    of,    after    abdonunal    myomec- 
tomy, 551 
after  removal   of  large   interstitial  my- 
oma, 551 
L'tero-ovarian  ligaments,  adenomyoma  of,  360 
changes  in,  with  myoma,  356 
cysts  of,  with  myoma,  350,  357 
myoma  of,  358,  360 

secondary   sarcomatous    nodule   in,    with 
myoma,  360 
Uterus,    adenocarcinoma    of,    associated    with 
myoma,  274.     See  also  Adcunrnrcinomd  of 
vteruf!. 
adenomyoma  of,  167,  168,  511 
angiomyoma  of,  158-161 
Uterus    bicornate,  diffuse  adenomyoma  in  one 

horn  of,  157 
Uterus,  bisection  of,  for  myoma,  60S,  683,684, 
685 
broad  ligaments  of,  ab.scess  of ,  and   myoma, 
354,  3.55,  510 
Uterus,  carcinoma  of,  485 

associated    with    myoma,   295,   296.   404, 
405-416,  485 
enlargement   of,   due  to  retained  menstrual 

flow,  485 
fibroids  of,  1.     See  also  Myoma. 
fil)roma  of,  1.     See  also  Myovta. 
filjromyoma  of,  1.     iiee  a\so  M ynwa. 
hypcrtropliy  of,  in  myoma  ca.ses,    1 1 
infection    of,  from  carcinoma  of  uterus,  after 

abdominal   myomectomy,  540 
inspection    of,    in    differential    diagnosis    of 

myoma  and  pregnancy,  467 
interstitial  myosarcoma  of,  171 
intraligamentary  myosarcoma  of,  171 
inversion    of,    associated    with    sulimucous 

myoma,  71 
large  suppurating  myoma  oj^'ning  into  cavity 

of,  151 
lipomyoma  of,  162-166 
malformations   of,  associated  with   myoma, 

I.").")-157 
myoma  of,  1.     See  al.so  Myoma. 
myosarcoma  of,  169-261 
pain  in,  with  myoma,  448 


INDEX. 


'23 


Uterus,    perforation     of,  due    to    suppurating 
interstitial  myoma,  150 
position  of,  with  myoma,  11 
prolapse  of,  associated  with  myoma,  400 
rerurroiit  fibroids  of,  178,  179 
round   ligamonts  of,  with  myoma.  361,  o6'2, 

363,  364,  603 
rupture    of,   during    vaginal    niyomertomy, 

576 
saddle-bag  appearance  of,  in  myoma  cases,  o 
sarcoma  of,  myoma  and,  492 

relation  of  hyaline  degeneration  of  myoma 
to,  93 

resembling  myoma,  216 
submucous  myosarcoma  of,  171 
subperitoneal  myosarcoma  of,  171 
suspension   of,   during  abdominal    myomec- 
tomy, 525 
torsion  of,  in  myoma  cases,  77 

with   complete   severance   of   body   from 
cervix,  with  myoma,  79 
tuberculosis    of,    associated    with    myoma, 

421 
unusual  sarcoma  on  surface  of,  184 
with  dead  fetus  resembling  myoma,  473 


Vagina,  abscess  burrowing  along,  196 

alterations  in  size  and  shape  of,  with  myoma, 

439 
bluish  color  of,  with  myoma,  439 
condition  of,  with  myoma,  438 
double,  with  sul)mucous  adenomyoma,  155 
expulsion     of     large     submucous     myoma 

through,  67 
ulceration  of,  with  myoma,  440 
vein  stones  in,  with  myoma,  440 
Vaginal  cysts  with  myoma,  439 

discharge  with  submucous  myoma,  67,  571 
drainage   after   alxloiniiial    hystcromyoniec- 

tomy,  623,  624 
examination,    thiili    felt    on,   witli     myoma, 
442 
Vaginal    hystcromyomcctomy,    (529,  (570,  (572, 
685 


Vaginal  mucosa,  bluish  color  of,  in  myoma,  439 
Vaginal  myoma,  234,  440 

Vaginal  myomectomy,  571.     See  also  Myomec- 
tomy,  vaginal. 
portion  of  cervix,  elongation  of,  with  myoma, 

441 
vault,  induration  of,  with  myoma,  440 
wall,  ))hleboliths  in,  with  myoma,  440 
Veins,  abdominal,  enlargement  of,  with  myoma, 
437 
iliac,  compression  of,  by  tumor,  234 
ovarian,   thrombosis   of,   after   hystcromyo- 
mcctomy, 222 
thromliosisof,  in  utci'inennicosa,witli  myoma, 
320 
Vermicular     contraction     of     ureters     during 

hystcromyomcctomy,  385 
Vermiform    appendix,   removal    of,    after   ab- 
dominal myomectomy,  557,  558 
Vertebrae,  metastases  in,  from  myosarcoma  of 

uterus,  176 
Vesical   adhesions,    release   of,    subsequent    to 
abdominal  myomectomy,  556 
role  played  by,  in  myoma  cases,  366 
calculus  associated  with  myoma,  375 
Vicarious  menstruation  after  abdominal    hys- 

teromyomectomy,  605 
Vomiting     after    abdominal    hystcromyomcc- 
tomy, 658 
myomectomy,  548 
associated  with  myoma,  447 
stercoraceous,     after     abdominal     hystcro- 
myomcctomy, 658 
myomectomy,  548 
N'ulva,  pruritus  of,  in  myoma  cases,  444 

Water-core  appearance   in   areas  of  hyaline 
degeneration.  95 

Weakness,  profound,  in  myoma  cases,  4.")7 

Weather,   hot,  as  cause  of  postoperative  ele- 
vation of  temperature,  655 

Weight,  loss  of,  in  myoma  ca.scs,  456,572 
of  myomata,  119,  512 

Worms,    intestinal,    after    alidomiiiai    liystero- 
myomectomy,  659 


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